Category: health

Financial parasites in the healthcare world

Financial parasites in the healthcare world

Healthcare is big business, with medical practices vying for contracts, hospitals undergoing facelifts in order to cater to patient experiences, and insurance companies making deals with pharmacies.  Some of these arrangements are negotiated in the name of reducing healthcare spending, but there has to be some skepticism when for-profit entities are implicated.  Physician salaries aren’t exactly growing with inflation—some fields have had massive cuts in spending over the years too.

The problem with these stagnant and reductions in physician salaries are that they are targeted in the name of curbing healthcare costs since there are no more dollars to be distributed in the system.  All the while, the number of administrators and middlemen/women in the system consume more healthcare dollars.  Yes, this may be an oversimplification of the problem, but I’ve seen hospitals hire minders to explicitly observe whether a healthcare worker uses hand sanitizer in front of a patient!  Talk about waste in healthcare dollars!  When you slash the compensation of the people on the ground while making them do more work, there will undoubtedly be unrest.

From fast food to healthcare
Just as how a successful fast-food business such as McDonalds relies on its workers to function, healthcare relies on doctors, nurses, and allied health workers to run.  However, this is just about where the similarities end. In the fast food industry, these workers are entry-level employees that keep the ship running.  One could argue that this industry takes advantage of the labor to pad its shareholder profits and administrators’ pockets.  This industry also provides a means for someone to earn income.  If the employee does not like the management, she could simply leave and find another occupation.  If this person wanted to open her own franchise or establishment, she could do so (yes it wouldn’t be easy but possible).  There is no particular skillset that ties down the fast food worker to the business.
Unfortunately physicians aren’t all able to do the same for a number of obvious reasons.  Many medical specialties are bound to hospital care, simply due to the subspecialization of their trade.  Intensivists, for instance, have specialized training for care that can only be delivered in an intensive care unit.  Other specialists who have traditionally been able to practice medicine on their own are more restricted today by insurance contract limitations and high costs of startup.  The amount of student debt that many younger doctors have makes it challenging to take out loans to start their own medical practice.  Hence, many physicians are stuck laboring away to supply jobs for many other healthcare workers.

Golden handcuffs
I’m not sure what to think about how my labor supports the jobs of dozens of healthcare workers.  Are these workers all needed for you to do your job? How much of that other person’s salary could be going into your pocket? How much of healthcare dollars could be saved if you weren’t required to have a certain number of staff under your name?  Let’s look at a real example:

Take, for instance, the number of supporting staff for a moderate volume ophthalmologist.  Her clinic has three technicians dedicated to her, along with shared front desk and ancillary staff.  The local ambulatory surgical center has an equivalent of 1.0 FTE scrub tech and circulator essentially dedicated to this surgeon.  There is also a CRNA who generates a third of her weekly salary from that surgeon.  This amounts to essentially 4.3 FTE plus front desk that is feeding from a single doctor!

Mutualism, commensalism, or parasitism?

This amounts to $210,000 of additional healthcare dollars used, feeding over four full-time workers!  The bigger question is whether these workers are needed in order to deliver care in the system.  How much would one fewer office technician impact productivity?  Would a decrease in a $55,000 salary reduce overall revenue by $70,000 but improve the sanity of the doctor by a tenfold?  Is the doctor mandated to have this set number of support staff by the medical practice? 
The predicament that many doctors face is that they are not able to exit the system.  Their skills are tied to an inefficient system.  If they were to leave, most other options are likely similar to the system that they sought to escape. 

How many financial parasites do you have in the workplace?

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Air travel during the busiest travel season during 2020

Air travel during the busiest travel season during 2020

For obvious reasons, travel across the board in 2020 has been at an all-time low.  Business travel and medical conferences have mostly been supplanted by teleconferencing and pre-recorded streams.  Cruises are all but nonexistent for the foreseeable future.  Air travel has also been discouraged in order to curb disease transmission, but this Thanksgiving week has seen record high numbers of air travelers since the beginning of the year.  It would be interesting if there were a means to tally the reasons why people are traveling (i.e. emergency vs leisure), but I would suspect that any increase in travel is mostly for leisure purposes.  

Complementary 70% alcohol wipe to clean your own tray table!

We can all agree that there is little consensus in what we should do collectively to curb COVID19 spread, and everyone including medical doctors seem to have their own convictions on what constitutes medical truth. 
I recently traveled cross country to care for family.  The following is an account of my observations of air travel this year.  

Flights will still be packed

While some airlines are still blocking out seats on their aircraft to help with social distancing, many no longer do so.  During the early months of the pandemic, many carriers were still flying their planes despite the lack of passengers.  This was due in part to certain stipulations required for governmental loans and stimulus packages.  Now that the window and requirements are exhausted, airline carriers are operating to reduce financial losses.  The flights I took had only several empty seats, so there was no opportunity to social distance.

The gates during the boarding process tended to be crowded just like the pre-pandemic travel times.  Flights did board from the rear of the airplane first, which presumably helps expedite the process.  Once boarded, however, everyone is still stuck like sardines.  The flight attendants did make periodic announcements for the passengers to keep their masks on, but I’d imagine that they were in a no-win situation when passengers do not comply.  On one of the legs of my flights, my seat mate was actively coughing and kept his mask off during the entire flight.  
In-flight service are also limited.  Beverages are still offered, but in-flight food sales are not.

Will flights actually get you to your destination?

The premise of traveling is being able to arrive at your destination safely and timely.  From what I’ve experienced, airlines have done their best to make travel as hygienic as they can.  The cabins are sprayed with electrostatic cleaning agents between flights, and air is filtered using HEPA filters.  I was given a 70% alcohol wipe to clean the armrests and tray table when I boarded my United Airlines flight.  Overall, this is probably as much as airlines can do to convey that air travel is still safe.  

Reliability of arriving at your destination, however, remains hit or miss.  On the one hand, most airlines have waived change fees.  On the other hand, passengers are also subject to the whim of schedule changes and rebookings that airlines initiate.  This means that sometimes your originally scheduled flights are cancelled, and you are rebooked on a different flight that hopefully arrives at your destination roughly at the same time as your original flight.  Airlines generally do a decent job getting passengers to their destination on time. 

Where do people actually transmit disease?

In-flight COVID19 transmission has been shown to be limited in most studies/reports.  Based on this logic, air travel is likely safe.  However, travelers have many opportunities outside of flight to become exposed to aerosolized particles.  Those additional contact points increase exposure risk. 

Air travel is probably as safe as it can be during these tumultuous times, albeit uncomfortable.  I would certainly not travel again unless absolutely necessary.

What are you impressions of air travel during the pandemic?

Physician Burnout – an alternative analysis

Physician Burnout – an alternative analysis

Physician burnout has been a much discussed subject in recent years.  The term itself is often broadly defined, but the general consensus is that burnout frequently describes a feeling of unhappiness.  This unhappiness is often directed towards or fueled by the activities that one has to endure throughout the day, week, or an entire career.  Some people have described burnout as having to deal with a series of activities that we dread.  In response to physician burnout, hospitals and employers have invested into significant programs to “remediate” their physicians. 

I have yet to find any legitimate study supporting the efficacy of these remedial programs, but there is clearly an increase in coaching services, self-help manuals, and aids to combat this growing problem. 

Sometimes we are burning on down to the wire.

The source of physician burnout has been attributed to a multitude of reasons, many stemming from increasing regulatory demands in the workplace, more menial work with electronic health records, and even motivational huddles mandated by administrators to combat the very same problem.  There is no doubt that these issues contribute to disgruntled physicians, but there is another problem in our modern healthcare system that is not as commonly discussed.

Your patient is part of the problem

Medical training emphasizes the need to put patients before ourselves.  The Hippocratic oath reminds us not to do harm, and we frequently go out of our way in order to get patients the best outcome.  In medical school, we undergo simulated scenarios to diffuse conflict.  We are taught to emphasize with the patient.  Doing so is entirely reasonable and an appropriate exercise for everyone in healthcare, but is it the right approach?  Empathy is certainly the socially acceptable answer, but the dark side to empathizing with those we care for is that undoubtedly we end up biting our tongue and perhaps compromising what our moral compass tells us otherwise.  

We’ve all had our unpleasant patient and workplace encounters.  It’s part of the job, and somehow we’re all expected to brush aside these experiences and continue throughout our days as though it were only a scratch.  But we can all attest that the frequency of these encounters has gradually increased over recent years.  No matter how insignificant, these battle scars build up.  We internalize the pain.  We remember the good and the bad cases, and not infrequently, the bad ones are the ones that gall us during our entire career.  They cause us to toss and turn in our sleep, disrupt our family lives, and even cause physical ailments.
These unpleasant experiences are uncommonly justified, and they sting.  Here are a few scenarios that we end up dealing with in our daily lives:

  • A patient demands a refund on their copayment after a visit because they are unhappy for their care.  Then they ask for a copy of the visit record. (You can’t legally void a patient visit afterward if you are accepting health insurance.) 
  • An unreasonable patient lashes out with an unfounded social media review on a 3rd party ratings website.  The physician’s office is unable to remove the review because these websites actually hold business reviews hostage.  But these websites are quick to push their services onto your practice.
  • A patient hammer calls the office with questions that should be asked during a patient visit in order to avoid paying a visit charge.  

Medical practice is burning us out
If doctors have always taken care of patients, why are we only burning out now?  Two reasons come to mind: (1) the healthcare environment is constantly evolving, and (2) both good and bad information is more readily accessible to the lay public.

The healthcare system is complex.  Much of the complexity is due to trying to fund uncontrolled expenses with a finite and insufficient budget.  For the workers involved in direct patient care, this has translated into limitations on our resources.  Our profession was built on physician autonomy.  Physicians have always chosen how to diagnosis ailments, and how to treat them.  Our current system imposes strict financially driven boundaries on how physicians can practice.  In principle it is great to make healthcare decisions based on prudent cost-saving measures.  However, drug formularies are not all created equal.  We have all experienced health insurance denials of our recommended treatment regimens only to find that what is recommended by health insurance is not equivalent by any standard.  Physicians are now having to fight more than ever with insurers and regulators.  This is a mentally and physically exhausting endeavor.

Properly informed patients are a blessing, but there are problems when people are armed with misinformation or are unable to arrive at the appropriate conclusion even with correct information.  This situation is increasingly more common with easy access to online information.  We see this among healthcare workers as well—we are sometimes armed with the wrong information, but unable to correct our shortcomings due to pride and ego.  As physicians we have always struggled with the paternalistic desire to do the right thing, offer the facts, and arrive at the best possible solution for a given situation.  It is a struggle whenever we our recommendations do not align with what our patients expect.  The patient as a person is not the problem.  It’s the availability of unfiltered content open to erroneous interpretation that causes stress.  When you throw in the complexities of health insurance that no one truly understand completely, you have are surely going to struggle.  Repeated struggles will burn anyone out.

Bringing the sources of burnout to light

Physicians shouldn’t have to dread their work.  Our patients don’t deserve to have doctors who are burnt out either.  But our current system has made it easy to stress out and find blame.  Those of us near the end of our careers can surely attest that practicing medicine just isn’t what it was used to be.  It is now up to the current and future generations of physicians to make medicine great again.

What aspects of medicine do you dread?

Protecting your financial future from other physicians

Protecting your financial future from other physicians

Unfortunately, hospitals and healthcare systems are not the only ones that take advantage of doctors.  Physicians in private practices are just as likely to take advantage of their colleagues, and sometimes the severity may be much greater than what you’d see in the hospital setting.

Those of you younger doctors in outpatient specialties, take note.  This list includes gastroenterologists, ophthalmologists, vascular surgeons, oncologists, internists, or anyone who would join a medical practice with another doctor.  Anytime there is a younger physician joining a practice run by senior physicians, there will always be potential for inequity.  Why do these problems arise?


Greed of money, and greed of exploiting someone else. It just happens.  Perhaps the senior doctor thinks that she put in blood and sweat into a practice that a junior associate is simply getting in for free.  Blood must be drawn in order for a new doctor to be accepted. 

How you can get taken advantage of as a junior doctor
Most of us learn from getting burned ourselves.  These situations can occur in any of the common three ways:

  1. Reneging on a prior promise — This is typically the most obvious scenario that younger doctors encounter.  A new doctor joins a practice with the promise of partnership after a certain period of time.  When that time is reached, the owner-physician declines the partnership offer for some infraction.  The junior doctor is then stuck remaining as an employee indefinitely or move elsewhere.  Sometimes this cycle repeats with a new hire.
  2. Withholding critical financial information — Sometimes a partnership isn’t really a partnership.  Or maybe not all partners are created equal.  The problem with healthcare is that there are business nuances that you will only learn with experience in your profession.  This is where a less experienced physician can get taken advantage of during a partnership agreement.  
  3. Exploiting mentorship role for financial gain — Greed.  It never makes sense to me that a physician who has had an entire career of earnings would feel the need to maximize financial gain of a younger physician.    Typically the amount of financial gain is quite negligible for the senior doctor’s retirement plan.  I’ve seen instances where the senior doctor owns the building in which the practice rents from, and the lease arrangements benefit the landlord significantly.  I’ve seen instances where the junior doctor is heavily dependent upon the senior doctor’s goodwill to refer patients over, but the senior doctor does nothing to help the cause.

Justification of greed
Why do we even see doctors getting exploited by others in their profession? The answer likely lies in the competitive nature of those who enter the profession.  Look back to medical school—we all have been witnesses (or instigators) to cutthroat behavior in medical school.  There is a desire to get ahead.  These behaviors carry over onto everything we do. 
Those of you just starting your careers will need to be aware that malfeasance can happen anywhere and anytime.  Even if you ask the right questions and do all of the right things, you can still get swindled financially by a fellow physician.  
Those of you who are senior physicians bringing on junior physicians, be mindful of what you went through and try to mentor your younger colleagues properly and fairly.  Do the right thing. Our profession needs to stick together to fight the good fight. 

Pandemics, hoarding, and the human psyche

Pandemics, hoarding, and the human psyche

Having a level mindset in times of angst is always a good skill to have.  Fortunately in the last century, there have only been a handful of events that have stressed the world’s economy to cause widespread concern.  9/11 is one of those more recent events that come to mind.  Other major natural disaster events like the Haitian earthquake and the tsunami in Japan that resulted in a nuclear power plant meltdown both resulted in significant angst among the region affected.  Those who were not directly impacted (myself included) simply donated to a relief organization or did nothing at all.  Did those events affect the world’s economy? Yes, but not necessarily to the extent that huge numbers of people end up losing their jobs or livelihood.
Fast forward to the year 2020.  The world is talking about COVID-19, a real modern day pandemic.  Perhaps this virus will go down in history as the most widely known and literally widespread infectious disease in the last century.  I’ve medical colleagues who had no clue what MERS did back in 2012, but the severity of COVID-19 has at least made them acknowledge that there is a problem.

People, by nature, don’t like missing out on the action.  It doesn’t matter whether the action is free.  If the local ice creamery is giving out free ice cream, you’d bet that there will be a line.  It doesn’t matter if the wait is an hour in the blistering sun—there will be people (myself included) who would consider lining up for it.  Likewise, we’ve all lined up waiting for restaurants too. It doesn’t have to be the newest steakhouse on the block or the newest sushi bar in town either—even fast food chains can have long lines.  Sometimes the allure of long lines actually conveys to customers that the food is worth waiting for.  You be the judge of how long one should wait in line for a good hamburger.

Take a little betadine along with your morning coffee!

The COVID-19 pandemic of 2020
There’s no missing out on COVID-19.  It’s widespread, high contagious, and without direct treatment.  Governments have been rolling out mass testing with various degrees of success.  More importantly, the consensus is to avoid social contact.  This does not decrease the total number of people that will ultimately be infected, but spread out the number of infected individuals over a longer span of time.  By reducing the rate of transmission we can hopefully reduce the burden on the healthcare infrastructure, and hopefully decrease the mortality of disease.

Social distancing implies that we should avoid social gatherings and minimize time out in public spaces. This includes restaurants and even grocery stores.  

How many weeks of toilet paper should one stock up on to weather the novel coronavirus? It’s interesting how panic buying comes into the equation when there is even a hint of scarcity.  Milk, eggs, bread…many of these staple items are now consistently in short supply as of March 2020.  As certain restrictions, social distancing mandates, and quarantines occur, how much people decide to hoard will be fascinating to observe.

What goes on in the human mind

Much research has been conducted on human behavior.  Instinctively we are programmed to survive, even if it means being selfish.  We are definitely seeing instances of selfishness in human behavior during a stressful time in our lives.  We are also seeing acts of selflessness in the world too, with healthcare workers putting their own lives at risk to care for others, and many corporate entities contributing significant resources to supplies and manpower to fight the disease.
It will be interesting to see how the economy and society will play out over the next few months.

Stay safe and wash your hands everyone!

The real financial cost of taking research years in medical school

The real financial cost of taking research years in medical school

About 15% of my medical school class decided to take at least one research year during medical school.  This was in addition to the 8% of the class who enrolled as MD/PhD candidates, the five who already held PhD degrees before enrolling in medical school, and another two that I know of who ended up obtaining a PhD after medical school.  Roughly another 3% spent extra time during residency or fellowship to conduct research.  Based on these figures, one could conclude that my medical school was heavily research oriented.

The majority of medical schools don’t graduate students with such high frequency of extended academic training, and most medical students aren’t going to be interested in a career in research either.  There are plenty of doctors who have a PhD degree who also practice strictly clinical medicine, and many who hold many research grants without ever holding any additional advanced research degrees.  
What isn’t really a surprise but often gets neglected when future doctors make career decisions is how their financial future is impacted by extending their education.

Time is money
We all understand that the longer that we have investments into the market, the more likely it will have time to grow.  This finding has been modeled repeatedly in the financial world—if you invest while in your twenties, you will likely have a greater net worth than your counterpart to only starts in their thirties even if she can save twice as much.  We frontload our Roth IRAs and 401ks for the same reason.
Delaying your career by a few years will likely shorten your overall working career.  All things being equal, this might cut out a few years of your peak income.  This could be perhaps a quarter million dollars for every “lost” year for internists or double that for high-income specialists.  If you consider inflation adjustment, then the absolute difference will be even more.

The argument for taking additional time
Obviously one’s career shouldn’t only be about getting ahead financially, although we’ve all made choices to help improve our own situation in life one way or another.  Ultimately, it is you alone who will determine what you consider to be successful.  

Many students at top research medical centers opt to take additional time to conduct research

Taking a research year during medical school has many benefits, the most important of which is to have dedicated time to reflect what the essence of a particular field has to offer.  There is often limited time during clinical rotations to explore subjects in depth, as we are subjected to tests, presentations, and simply reading condensed summaries on topics at hand.  With limited direction and time, medical students essentially make career-impacting decisions.  I have plenty of coworkers and students who decided to pursue other specialties after spending a year conducting research in another.  What’s the ROI on spending a year to decide what to do with the rest of your life?


Dedicated research in a particular field will also strengthen one’s application for residency.  For some students, this might determine whether they’d enter a high-paying competitive specialty.  In this case, there is a financial advantage to taking additional time to make a career choice.

The bottom line

Clearly there are many roads to Rome.  The end goal in life shouldn’t be to have the biggest bank account either. For such a complex profession such as medicine, the path is not always going to be clear.  The advice that I give my medical students is that we should all be aware of the financial ramifications of our decisions, but we’re also in the business of improving lives.  If it takes an extra year or two for a future doctor to identify what she will be comfortable with doing for the rest of her career, then so be it.

What are your thoughts on taking research years in medicine?

Doctors net worth strategized

Doctors net worth strategized

There’s a fetish in the financial world to track one’s net worth.  Maybe it’s a chauvinistic means to compare one’s success to others’, or simply a means to build accountability to reach one’s goals.  I certainly felt great looking at a line graph with a positive slope documenting my net worth when I became interested in the subject.  The years that the bull market plowed ahead produced very steep slopes, while more recently the growth has been mostly stagnant.  Whether any of the positive slopes were related to my own doing, I sure felt great about it. 

We should all strive to have net worth graphs with positive slopes.  Most doctors’ net worth line graphs should have positive slopes—the only time should be if there is no income, working or from investments.  Either way, it’s not good for anyone to have a stagnant net worth slope.

One interesting discussion that we often hear from the doctor’s lounge how one’s life would have progressed differently if we had opted for a career outside of medicine.  These conversions materialize so often that sometimes it seems that all doctors are disgruntled about their jobs.  The reality, unfortunately, is that these conversions stem from burnout or some aspect of our jobs that we don’t enjoy.  

One interesting thought exercise that is often discussed is how life would be if said doctor opted for a career outside of medicine.  Let’s take a look at the financial differences in one scenario:

Software developer vs Hospitalist
These projections are relatively broad in assuming that the software developer is moderately successful in her field of choice, since her alter ego in another life ends up becoming a doctor. Both cases do assume relatively intelligent but not necessarily draconian financial comprehension.  

Getting a $1 million net worth by age 36 isn’t bad. Believe or not, many software developers hit seven figure before that without any chicanery…

The software developer begins her career with only a Bachelor’s degree, although this field typically doesn’t necessarily require an advanced degree to move up the ladder.  What one can conclude on this is that you don’t have to be a doctor to become a millionaire, and all that it takes is a good steady income and time.  It doesn’t hurt that a career that only requires a Bachelor’s degree will allow an individual to enter the workforce in her early twenties, effectively adding nearly a decade to the working career.  This financially mindful software developer is able to build a net worth of $1 million before the age of 40!  With tactful financial planning and grinding away over time anyone with moderately good financial firepower ought to build a healthy net worth.

Let’s take a look at the Hospitalist financial trajectory:

You worked 16 years for this?

You can see that the doctor has to start her career later and with a hefty student loan balance compared to her software engineer alter ego.  The financial trajectory will depend largely on the doctor’s specialty and income potential—the Hospitalist in this example likely has longer hours than the software developer and only has marginally higher net income during her peak years.  I chose this example to show that your income range as a doctor really determines how much spending power you have.  There are plenty of medical specialties whose income is comparable to that of many other non-healthcare professions.  

A doctor household with a stay-at-home spouse will have less financial firepower than a household of, say, two mid-career upper management engineers.  

What this means is that just because you are a doctor, you still shouldn’t spend more than what you income allows.  This means that Pediatricians shouldn’t be buying as much as Neurosurgeons (Sorry Peds! We will keep fighting to make sure that your profession becomes better recognized for your care!)

If you look back at the Hospitalist net worth trajectory, she will still be able to hit a seven-figure net worth before the age of 50.  With either more income or strategic financial planning, she can still live a comfortable, but busy, lifestyle that rewards her for spending her twenties in the basement library of her medical school.  The next time you roll your eyes when the ER calls you for your eleventh admission of the evening when you have no cap on admissions, remember that as a doctor you can still build up your net worth, piece by piece.

Don’t know where to start? Consider going through some of our previous articles: