MD Articles

http://www.cms.hhs.gov/AcuteInpatientPPS/Downloads/AMGA_08_data.pdf
http://ifap.ed.gov/sfahandbooks/attachments/0102Vol8Ch3loanperiodamts.pdf
http://www.science.fau.edu/student_services/prepro/ppGuideRev_2007.pdf
http://www.physiciandepot.com/Physician-Salaries.aspx
http://mdsalaries.blogspot.com/2007/02/allergist-immunologist-physician.html


By Thomas A. Breslin
and Carlos Martini
Posted July 19 2004

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After nine years of carefully studying South Florida's health care climate, we at Florida International University concluded that our area cannot rely on its existing medical schools to meet the region's need for doctors.

The 100-plus page proposal for a medical school we presented to the Florida Board of Governors earlier this month outlines the economic feasibility of this project and paints the impending shortage of doctors in hard numbers. We found that:

The American Medical Association has abandoned its policy that the nation has a doctor surplus. It continues to be concerned with shortages of Hispanic and African-American physicians.

Florida depends on other states and countries for 80 percent of its doctors. It is also the state with the greatest dependence on the uncertain supply of foreign-trained physicians. Thirty-six percent of its physicians, compared to 24 percent nationally, are foreign-trained. In South Florida, over 40 percent of the physicians are foreign-trained.

Florida has the oldest physician workforce in the nation, with one-quarter of doctors age 65 or older. In South Florida, approximately 52 percent of physicians are 50 years of age or older.

Within the next 15 years, the state will receive 5 million more residents.

With the state's public medical schools located in the central and northern Florida, not quite 4 percent of South Florida's 14,000 physicians come from those schools.

University of Miami and Nova Southeastern University, both private institutions, provide medical education in South Florida. For those services, in fiscal year 2005, the state is paying nearly $15 million to the University of Miami and $5 million to NSU.

This public-private partnership concept is sound, but more is needed. UM provides just 10 percent of the region's physicians; NSU, 3 percent. Furthermore, while UM has announced it will add 32 first-year medical school seats at a satellite facility in Boca Raton, it also announced a commitment of 35-first year seats to out-of-state students. What's more, Floridians will pay UM $28,670 in tuition costs, about twice the tuition at University of Florida or University of South Florida.

So, the state's efforts are producing only 17 percent of our area's doctors, and too few of those are minorities.

Further expansion of existing medical schools is just part of the solution. Of the established medical schools, only NSU can expand without renovation or new construction. Expanding the public medical schools would cost an estimated $75 million, with little benefit to South Florida.

These figures underscore South Florida's need for a public medical school to serve its very diverse and growing population. FIU has a large student body that reflects this population. FIU graduates more Hispanics than any university in the country and is 20th in the number of blacks graduating with science, engineering and mathematics degrees.

Will an FIU medical school be cost effective? The thorough proposal we sent the Board of Governors shows we can.

Four prestigious area hospitals have said they would cooperate with FIU, eliminating the need to build a teaching hospital from scratch. Costs to the state will be generally in line with costs at UF and USF; so will tuition. A projected FIU annual tuition of $14,700 would open the field to many talented Floridians.

Because new MDs must complete a residency program before practicing and they tend to settle near their place of residency training, there is legitimate need to add more residency positions in Florida; residency programs here have reached capacity. Hospitals and clinics that want residency programs need expensive faculty and educational resources that are best provided by a new medical school nearby. Several hospitals and clinics are already strongly committed to residency programs affiliated with FIU. These programs would immediately boost local physician supply and improve health care.



Our proposal embodies years of homework on this issue. We look forward to working with our colleagues at UM and NSU to give our region the medical care it deserves and needs.



Thomas A. Breslin is the vice provost for academic affairs and Carlos Martini is director of the Medical School Project for Florida International University.
__________________
Moderator - State Licensing Forum

Still skeptical after all these years.
This is it. There are no hidden meanings.WYSIWYG

comes to wonder why they even put a med school in FSU instead of orlando and ft laudy. they cant even train the doctors fully in that rural setting. half the lawmakers went alumnus of FSU and they still wanted to compete with UF. now they are hesitant to approve more schools because of lack of financing. it is actually current schools that lobby against expansion which i feel is ridiculous. its all stupid politics. if it just was money..... i know of many private schools that would set up shop. it is the beurocratic bundle. look at NY with a comparable population to florida. they have 13 medi schools to floridas putrid 4 which was 3 not long ago.
__________________
Dr. Scott
Internal Medicine
PGY-2


How to Go to Medical School for Free
By Kim Clark
Posted June 2, 2008

Corrected on 6/04/2008: A previous version of this article said that the military scholarship programs require two years of service for each year of scholarship received.

A growing number of government agencies, universities, and charities are trying to ease the burden of medical school by offering free or nearly free rides.

That's worth a lot. Even if you go to your home state's medical school, the sticker price on a medical degree will very likely top out at $140,000, including room and board. Double that amount for a degree from a private school. Of course, when you finally finish your four years of school and minimum of three years of residency, even low-paid family practitioners usually get an annual starting salary of at least $143,000, while orthopedic surgeons start at almost three times that.
Click here to find out more!

But before you apply for any medical school funding, check the fine print. Many of the good deals have some heavy-duty strings attached. Military scholarships, for example, typically require students to put in two years of service for every year they received a scholarship.

Completely free ride—tuition and living expenses—with few strings attached:

The University of Central Florida is offering completely free rides to all 40 members of the class of 2013.

Fine print: Next year will be the medical school's first year in existence, so there might be some first-year jitters.

Vanderbilt: A few full-ride scholarships for top-notch students are detailed here.

Washington University: A few full-ride scholarships for top-notch students are detailed here.

Completely free ride, with notable strings:

Military—If you're officer material, the military will pay your tuition and living expenses through four years of medical school whether you're in the Army, Navy, or Air Force.

Fine Print: Doctors generally serve one year of active duty for every year of scholarship they receive, but they must serve a minimum of two years.

Work in the boonies—The National Health Service will pay tuition and living expenses for those training to become primary-care physicians.

Fine print: Recipients will be assigned to needy areas and must work at least one year for every year of a scholarship. They'll also need to be good and lucky: The NHS gets seven times more applications than it has scholarships.

Researchers—The National Institutes of Health will pay tuition and a living stipend for those interested in spending the eight years in school necessary to receive an M.D. and a research Ph.D. through programs like its Medical Scientist Training Program.

Fine print: These scholarships are designed to help those who want to become research scientists, not Beverly Hills plastic surgeons.

Free tuition—Some scholarships cover only tuition, leaving medical students to pay for their living expenses, which can easily run more than $2,000 a month.

Cleveland Clinic Lerner College of Medicine of Case Western Reserve University will offer free tuition to all future medical students.

Fine print: The Cleveland Clinic focuses on training researchers and academics. You'll need to have good grades, scores, and luck. Last year, before the new scholarship program was announced, the Cleveland Clinic received 1,423 applications for its 32 slots. It'll probably be even more competitive this year.

Very low-cost tuition:

The Mayo Clinic promises every admitted medical student a scholarship of at least $25,000. That means students in the fall of 2008 will be charged no more than $4,200. And many will get other scholarships to cover that.

Loan repayment programs:

Serve in the backcountry—The National Health Service Corps will repay $50,000 in education debt for two years of service in needy areas. It will repay up to $35,000 for a third year.

Post-Residency Doctor Incomes in NY: 2007 Survey
While most income figures mentioned on this blog are often mid-career incomes, "exit surveys" from the outgoing batch of residents is a great way to gather information on the job market and starting salary offers for fresh-of-the-mill doctors. The University of Albany School of Public Health has been publishing workforce study reports for various occupations in the state of
New York since 1997. The 2007 report indicates a continued strong job market for physicians in US, with only 4% of the surveyed residents without jobs at the time of the survey.

Here are some of the median starting income offers ( pre-tax, base salaries + Bonuses)

Highest:

Orthopedics : $259,700
Radiology : $257,000)
Anesthesiology: $242,100
Cardiology $241,900

Lowest:

Primary Care Group (Family Medicine, Internal Medicine, Pediatrics) : $142,000
Pediatrics: $110,000

More notable excerpts from the report:

"Generalists received approximately the same number of job offers as specialists"

"Among the specialty groups, the highest median starting incomes were facility based specialties (including anesthesiology, pathology, and radiology; $247,000) and surgical sub-specialties ($238,800). Surgery-general experienced the highest average annual increases in starting income from 2002 to 2007 (11%)."

"Individual specialties seeing the greatest average annual increase were dermatology, pulmonary disease, and pathology"

"Ophthalmology was the only specialty that did not experience an increase in median starting income between 2002 and 2007."

An indirect indicator of demand for a specialty could be the ability to find a job in a location of choice.

"The highest percentages of graduates having difficulty finding a satisfactory practice position were in physical medicine and rehabilitation (59%), geriatrics (56%), hematology/oncology (42%), and pediatric subspecialties (38%). Conversely, otolaryngology (0%), pulmonary disease (0%), gastroenterology (4%), and ophthalmology (11%) had the fewest respondents reporting difficulty"

Hmm...I thought there was a relatively good demand for geriatricians - or maybe that demand is to surge when the baby boomers start retiring, peaking in 2020-2030.

Number of Job Offers Received:

"The mean number of job offers received by graduates in 2007 was 3.64"
"Dermatology (6.53) + gastroenterology (5.60) graduates received the most job offers."
"Neurologists received fewer offers (2.00) than any other specialty."

Hmmm...receiving more than 2 job offers is strong enough a job market for me ;-)

Wednesday, March 5, 2008
So what's this radiology thing all about, anyway?
This'll be a non-running post. My friend just read this post and called me, asking "WTF? I thought this was a RUNNING blog?!" Ok, I'm definitely diverging a bit here, but I did get a bit tired of writing about "well, crashed again on my run" alternating with "hey - I'm back! Well, kind of." So I'll diverge a bit and expound a bit more on the other part of my life that has retaken the lead in priority after a few months in the back seat to the Houston marathon.

What the heck does a radiologist do, anyway? Our specialty is image analysis, with a smaller component of image-guided procedures. This means reading X-rays, ultrasounds, nuclear medicine scans, CT scans, and MRI scans, as well as a smattering of needle-based procedures mostly centered around getting pieces of tissue from inside the body without resorting to open surgery. On average, radiologists in practice work 50 hours per week, and generally have very high job satisfaction on informal job surveys, with relatively few physicians leaving the field compared to other specialties. Reimbursement ($$$) for radiologists has also been particularly good as of late, and despite the looming inevitable budget cuts that will knock back radiology salaries by a hefty percentage, most radiologists are quite comfortable financially, even with $200K of medical school loans to deal with after graduation.

I am actually a "radiology resident", or "radiologist in training." The road to becoming a radiologist is definitely the hardest part of getting into the specialty - it is a highly, highly desirable job post, with more interested and qualified applicants than spots available. Deciding to traverse the road of a MD to radiology involves going pre-med in college and graduating with distinction (no slacking), then gaining acceptance to a medical school, which will then occupy 4 more years of your life. The average debtload from medical school alone is $150-$200k, and rising rapidly. If you're lucky or stupid enough to do the MD/Phd track as I did (less than 5% of MDs in general opt for this route), and devoted 4 years of my life specifically to PhD research in the middle of my MD training, the tuition for medical school is waived - but you've just lost 4 more years of your prime adult years as well.

Even then, you're not even close to home free, though! For radiology, you pretty much have to graduate in the top 50%, if not top 25% of your medical school class to have a legitimate shot at gaining a spot. The general routine is applying to 20 to 40 radiology programs around the country during the 4th year of medical school, and then you're left literally to the mercy of a computer-guided matching program that finds the best match between your picks and the programs that interviewed you. As a result, geographical preference can be severely limited, even as a strong candidate. This "matching" stage really is a critical moment for many in the medical field, for if you go "unmatched", it means that you were not ranked highly enough by any of your selected programs and thus your future in your selected specialty is unlikely to happen. (You would have to spend at least another complete year bolstering your application with research, or giving up altogether and going for something less competitive.)

Perhaps one of the worst parts of this process, is that there's very flexibility. If you take a few months "off" for any reason, you have to justify it in writing at any stage of your applications and provide evidence that you were doing something "medically relevant." You can't just switch jobs and specialties as you would, say, in a financial sector job - you're really locked in from the get-go, and any deviations from the accepted training guidelines will be well documented as a PERMANENT black spot in your record. Yes, this mark will have to be re-documented over and over again for every year that you renew your medical license, for the rest of your life (or career.) I would LOVE to take a year off from training to say, run or travel, and do nothing medically related, but the amount of administrative BS I would have to wade through for the rest of my entire career is simply not worth it.

Before starting radiology residency, you are pretty much forced to do a general "internship." This is the year of suffering that everybody fears, for good reason. It's your first encounter with real patients and real problems, and as the low guy on the totem pole, all of the badness, from undesired shifts, to god-awful procedures and scutwork, get directed to you. Still, things are orders of magnitude better than 15-20 years ago, where this internship position really was no better than pure slavery, and where sexual harassment and constant humiliation really were the norm. Enough horror stories emerged over the last 2 decades such that the national medical association now takes any reports of abuse quite seriously, and limits work hours in-house to 80 hours. These guidelines really have improved our lives, and I am grateful for them, as well as the oversight to limit intern abuse. My internship was challenging, as expected, but fully worth the experience. Furthermore, I experienced zero humiliation or ridicule while on service, and was treated as a valuable contributor to the medical team. This is good for both doctors and patients.

Life as a radiology resident is challenging, but amongst the more benign of the various residencies out there. It's sad to say it, but a large reason for this is that radiologists are insulated from direct patient care. "Frontline" doctors, such as the ER physician, or the surgeon, deal primarily the patient, and then come to us in consultation. As most primary caregivers will tell you, this means that you are usually not only dealing with the medical problem at hand, but with the constellation of psychosocial problems that come with them, ranging from things as serious as insurance lapses during critical chemotherapy, to mundane but extraordinarily vexing things such as patients unable to leave your office because they can't afford a cab ride home. Radiologists thus get the luxury of time, a controllable work environment, and in particular, efficiency in work since we can sidestep most of the non-medical issues as consultants, and primarily deal with physicians. The worst part of our job as radiology residents is the after-hour responsibilities, not affectionately known as "being on call." Meaning that you can get called or paged by anybody who needs you. Again, the type of calls we get in radiology are generally much more manageable than some other frontline caretakers. Typical "calls" I would get as an ICU resident were urgent calls because "your patient is about to die unless you do something NOW!" whereas my calls now are more for more leisurely complex diagnoses.

As pleasant as looking as pictures and talking to smart people all day sounds, there is a fair amount of stress during work. I definitely underestimated the vast amount of knowledge required for radiological sciences. Since starting a little of a year and a half ago, I have read about 30 super-dense radiological textbooks cover-to-cover, half of them of which are over 400 pages in length, and am constantly battling memory loss. If you runners think Lore of Running was dense, you would literally cry if you saw what I have to wade through. Reading Lore of Running is like reading a glamour magazine in comparison to the force-feeding of knowledge that I have to undergo on a daily basis. I average anywhere from 1 to 4 hours per day in academic reading, and this is on top of whatever work responsibilities I have. As you can imagine, TV, social activities, and going out, have pretty much disappeared. Aside from running, and moments online which I can squeeze in at weird hours, it's a full day. To ensure that we residents stay "sharp", there are annual exams, and in particular, both oral and written board exams in your final years, to ensure that you've gotten your fair share of minutiae. These exams are difficult, and sufficiently esoteric that unless you are specifically studying for them, there is little chance of passing by relying on everday experience. Perhaps the main thing that gets me through this otherwise tortuous task is my self-knowledge that I am particular good at what I do, and am motivated to maximize my potential in this wonderful field. I chose radiology because it plays to my strongest features, which is my ability to assimilate and synthesize detailed information in vast quantities. I have finely honed my time-efficient study skills to a razor's edge over my entire life, and I do feel that my lifetime commitment to this task has given me a substantial edge in my field, which allows me to accomplish learning goals which are considered insurmountable by most residents. This is highly relevant for running and marathoning because it frees up time for other pursuits such as marathoning. There would be absolutely, positively NO marathoning if I were struggling to keep up with standards as a radiologist. It's a luxury item for me!

Here are some photos of me at work at perhaps the nicest of our workplaces at the county hospital. As you can see, it's a physically sedate job - I'm on that chair pretty much all day. Minimal walking, and definitely no lifting. I do get called to do needle-based procedures about once a day, but those are quite lightweight as well. The bulk of my activities constititute pulling up a variety of films from a list on the computer, assessing them, and then dictating my report onto the computer system. A few clinicians come down to ask specific questions and have findings pointed out, but for the most part, it can be a pretty solitary experience. At UCLA, we do have great staff who are dedicated to teaching, and we can count on an hour or more of each day dedicated to didactic sessions separate from the typical workload.

Doing my thing

We also get fancy computers to maximize our clinical viewing. The monitors we use are super-high resolution, and the combined cost for one of the workstations pictured below is $40,000. Ironically, we occasionally are called to evaluate images while on duty at home when we're on a type of call where after hours, we get to go home, and we're then interpreting these very same images on a run-of-the-mill personal PC and a regular internet connection. Having such fancy computers is also a mixed blessing - it allows us to more rapidly acquire and view images, but it has also dramatically increased the quantity of work that we are supposed to throughput. It is pretty common for us to not be able to keep up with the flood of images coming into our stack.

This is the only room with a window I've EVER worked with in radiology - the rest are pitch-black caves, and nowhere near this nice


Getting paid as a radiology resident is completely non-negotiable. There is a standard rate set by the national residency councils with small cost of living adjustments for region, and that's what you get per year. It works out to about $40,000 per year pre-tax, or $10 per hour post-tax given my best per-hour estimate including call shifts and excluding the significant number of hours I spend for work-related reading. This doesn't sound bad at all (hey - at least we're getting paid at all!), but consider that most of the on-call duties that we cover would ordinarily require a physician or high-level nurse practitioner who would charge at least $150 per hour, if not close to $300 per hour for the exact same services, and you can start to see the disparity. As mentioned before, we also get the joy of having to cover all of the undesirable shifts, which includes weekends, evenings, and all holidays, with no overtime or bonus pay. It really is all about very, very delayed gratification in terms of the financial situation here, to the point that I don't even think about it anymore. I can't even fantasize about what I'll do with that attending-physician salary, since it's been so long at this level that I can't even imagine getting compensated reasonably for what I do. My car is inherited from my mom from 1997, I live in a shared apartment, own virtually no clothing worth more than $40 per item outside of my Brooks running jacket and interview suit, and generally am known as a perennial cheapo on the Runners World forums for advocating Target C9 gear in favor of fancier stuff such as Under Armor or Patagonia. It's definitely NOT a glamorous life as a resident (unless you or your parents are independently wealthy!)

Overall though, I really feel that being in the field of radiology is a privilege and wonderful experience. The benefits far outweigh the drawbacks, and most senior radiologists continue to practice into their late, late years, which is a good sign that they are not suffering from premature burnout. Most radiologists I know are very happy people, with little to no regrets about being in their field of choice. The major caveat to all of this, is the long and arduous road getting there which I have outlined above. As much as I love my field, I would counsel my own future children to seriously reconsider the long commitment they would be required to undertake if they decide to go a similar route to radiology. I will be age 35 before getting my first "real job", and will have had a combined total of 13 years of postgraduate training (8 years MDPhD + 4 residency + 1 fellowship) with zero time off and very little financial compensation commensurate to my work hours and qualifications. It's great once you're there, but wow, getting there can be a real ****.

That's about it for my boring "real" life when I'm not fantasizing about running a 3:10 BQ marathon. I've got a lot of other hobbies and interests in my previous life that I may expound upon later (Boo-Boo runner has voted for one of the many stories about my highly stressful youth as a Juilliard violinist), but for now, I'm off to do my 11-mile run with 6 tempo on the track. Good luck to you all in your various life exploitations - I'm always amazed at what other marathoners do during their non-running lives!

Year 2007 Sign-on Bonus averages for US Physician Specialties
The 3rd Quarter results of the Physician Recruiting Standard Survey for 2007 released by the Delta Group - shows an increase in the dollar amounts offered as the sign-ons to lure physicians...or an increase in the size of those carrots..

Here are the averages for some specialties from the Report for the 3rd Quarter for the Year 2007:

1. Cardiology: $25,000/-
2. Family Medicine : $18,000/-
3. General Surgery: $25,000/-
4. Hospitalist: $15,500/-
5. Internal Medicine: $15,000/-
6. Neurology: $21,000
7. Neurosurgery: $60,000/-
8. Pediatrics: $15,000/-
9. Radiology: $27,000/-

As compared to last year, the bonuses went up for about 80% of the physician specialties

These bonuses are either paid as lump-sum cash or are the value of services offered, like a hotel stay prior to the physician purchasing his / her own house.

Download the free figures for rest of the specialties plus average income survey results by the Delta Group Here



RESIDENCY SALARIES in United States
Resident = Bottom of the doc food chain ? ;-)

"Residency" and "Fellowships" in the USA are both a type of "Graduate Medical Education" - while Medical school would be classified as Undergraduate.

The 2008 Mean Annual Pre-Tax stipends in United States for a MD Resident (also called house-staff) from any specialty were as follows:

* 1st Year (PGY1 / Intern ): $46,000

* 2nd Year (PGY2): $48,000

* 3rd Year (PGY3): $50,000

* 4th Year (PGY4): $52,000/-

* 5th Year (PGY5): $54,100/-

* 6th Year (PGY6): $56,500/-


Note: These are means based on a national survey by the AAMC - the actual figures can vary by $3,000 to $4000 on either side of the mean, an at times more.

(Residencies like Internal medicine and Family Practice have a duration of three years, Neurology & Pathology is four years while General Surgery is usually 5 years, Neurosurgery 6 years.)


Chief Residents may or may not receive an additional stipend of $2000/- to $3500/- a year (not a rule), and sometimes may include a promise of getting into their fellowship programs


Note: Some places may even offer more depending on the cost of living - such as New York. Kingsbrook Jewish Medical Center is known to offer the highest residency salaries and here's the latest figures on the website:

PGY1 = $51,514.00
PGY2 = $56,137.00
PGY3 = $61,597.00
PGY4 = $63,209.00
PGY5 = $65,234.00


But then again, a Resident has some good perks & benefits - like most programs provide free food to residents while on duty, free laundry for their coats and free parking spaces...besides health insurance. As a sample, have a look at the Internal Medicine residency compensation and benefits at the Mayo Clinical college of Medicine, Arizona. Here's another example - Pathology residency and Fellowship Salaries at Baystate - Tufts Pathology Residency Program.Here's another sample look at salaries and benefits at Carle Foundation family Practice Residency


Lot of banks too open up to residents, providing zero-down payment loans for buying houses !



Q. Do Residency Salary Levels depend on the Specialty ?

No - Usually Residents of all specialties at a given institution receive the same salary levels, which rather depend on the year (i.e. PY1, 2, 3 or 4) . Salary levels may vary from one institution to another and often vary from state to state, as per living costs.

Q. Is there a difference in residency salaries of MD and DO (Doctor of Osteopathy) candidates ?

A. No, all are paid the same - MD (Americans and IMGs) and DO candidates

It is good to know that Residency Salaries and in fact for all Graduate Medical Education (GME) in the USA is paid for by mainly by Medicare and partly through state-level Medicaid funds, both of which are derived from tax-payers money in the US


Recently, the Centers for Medicare and Medicaid Services (CMS) have proposed a new payment structure for Residency pays to Hospitals hosting Residency Programs, Click Here to Read.


Residency Work Hours & Lifestyle - Most of the specialties are Hectic ! the most rigorous years of a physicians life - the 80-hour per week work limits now imposed on a resident have bought some sanity, but that limit is often transcended under the demands of patient care. Generally speaking, University Programs and University-Affiliated residency programs are more saner to work in as compared to the more busy community programs.

Related Reads about Residency Lifestyles:

A Day in the Life of an R1
7–8 a.m. — R1 pre-rounding

Each day, R1s will follow an average of five to eight patients. They use pre-rounding time to get sign-out from the R1 on-call the night before, discuss events with the nurses, review flow sheets, examine their patients and talk to families.
8–8:30 a.m. — Work rounds

The entire team meets in the team room to organize their work and patient care for the morning. The team consists of medical students, sub-interns, interns, senior residents, an attending, a care coordinator and team coordinator. This is also an opportunity for brief teaching sessions.
8:30–9 a.m. — Morning report

Residents and attendings from all disciplines attend morning report to review and discuss an interesting case. Morning report is run by the chief residents.
9–11:30 a.m. — Rounds

Ward teams meet and round after morning report. Teams “walk round” to each patient’s room. As a part of “family-centered rounds,” patients and their families, nurses and social workers join the medical team to plan care for the patient. The team coordinator facilitates rounds and performs administrative duties for the team throughout the morning. Bedside teaching by general medicine and subspecialty attendings occurs daily during this time.
11:30 a.m.–12 p.m. — Work rounds

The focus of this time is to help the post-call intern complete work, including sign-out, in preparation for getting everyone on the team to noon conference. This is also protected time to talk with consultants, touch base with primary care providers or perform other patient care prior to noon conference.
12:15–1 p.m. — Noon conference (Monday, Tuesday, Wednesday and Friday)

Faculty members from various disciplines present topics in a variety of formats. Lunch is provided. Evaluations are collected in order to improve the following year’s curriculum.
12:15–1 p.m. — Intern support group (Thursday)

Once weekly, senior residents take their interns’ pagers so that the R1s can participate in this session. The group is facilitated by a social worker, and the time is an opportunity for interns to confidentially share their experiences and partake in delicious snacks!
1–5 p.m. — General patient care

R1s follow up on issues or tests ordered on their patients. If on-call, they meet and admit new patients while being supervised by their senior resident. This is also a time when general medicine or subspecialty attendings teach on topics relevant to the team’s current patients. In addition to reviewing radiology images on our PACS system, residents also have the opportunity to review these films with a pediatric radiologist.
1–5 p.m. — Continuity clinic

Throughout the three years of training, residents follow a panel of patients at one of several community clinic sites. Continuity clinic is scheduled for one half day every week.
5 p.m.–7 a.m. — On-call

While on the wards, R1s are paired with a senior resident and take call every fourth night. On call, R1s will admit and work up new patients while also providing care to the remaining patients on their team until the following morning.

A night float system is in place to provide relief for admitting teams so that interns are protected from most new admissions after 11 p.m., allowing them to finish their work and usually get some sleep

A Day in the Life of a UT Southwestern Neurology Resident
As a PGY-2 Junior Resident on the General Ward Service …

7:00 AM
A new day - I start at morning resident rounds. During this session, the general neurology and stroke senior residents meet with the residents that were on call to hear about new admissions, consults and other active issues. Cases are distributed to the appropriate residents. Depending on the call rotation, I may receive new patients.

7:15 – 9:00 AM
Work rounds - I round on my patients to see how they are doing and review new lab or imaging results. I also familiarize myself with any new patients and prepare the history and exam presentation. I discuss any questions with the senior resident (the “ward boss”) on my service. On the general neurology service, I am likely to have a wide variety of cases. I may be caring for someone with an acute myasthenia gravis exacerbation, progressive MS receiving chemotherapy, Guillan-Barre syndrome, brain tumor, chronic meningitis or neurosarcoidosis – just to list a few… I’m also likely to see patients that have strange, undiagnosed neurological disorders. Most of my patients are on the 8th floor at Parkland hospital where the nurses and staff are all experienced in taking care of neurology patients. A few of my patients are located at Zale-Lipshy University hospital (which is connected to Parkland through a corridor).

9:00 – 12:00
Attending rounds - Our team is comprised of two to three junior residents and one senior resident. There are also usually one or two psychiatry or neurosurgery interns rotating with the ward service. We also have 3 to 4 medical students doing their neurology clerkship. Some of the medical students are assigned to help me with my patients. Teaching and supervising the students helps me to hone my neurology skills. During attending rounds, we review the diagnosis and treatment plans for our patients and learn under the direction of our attending faculty.

12:10 – 1:00
Noon conference. The core lecture series (on Monday, Tuesday and Thursday) is a 18-month course curriculum designed to cover all of the main areas in neurology, including neurological emergencies, neuromuscular, stroke, multiple sclerosis, epilepsy, pediatric neurology, evidence based medicine, medical ethics, business and career planning, etc… On Wednesdays, we have grand rounds with the whole department. This is a time to hear a visiting professor or one of our own faculty. On Friday, noon conference is focused on neuroanatomy and board review. During these sessions, we review a weekly reading assignment. This is a great opportunity to unwind and chat with my classmates at the end of the week.

1:00 PM
Back to the hospital to finish any remaining business. This might be some additional rounds with the attending or following up the necessary work-up and paper work on my patients. I may also evaluate new consultations that may have been requested throughout the day.
One afternoon each week, I have my Parkland Continuity Clinic. Continuity clinic is an opportunity for me to serve as the primary neurologist for the evaluation and management of my patients throughout all three years of residency. The clinic patient population is diverse and includes patients with migraine, epilepsy, multiple sclerosis, peripheral neuropathy, myasthenia gravis, movement disorders such as Parkinson’s disease and dystonias (including an opportunity to learn how to administer botox injections).

4:00 PM
The day is nearly done. The residents meet together to give the on-call resident a check-out of the current patients. If I am on call (every fifth night), I take the call pager from the emergency room resident and begin to receive calls. I am now ready to see new patients and handle any urgent consults. My senior resident is always available by pager to help me with any questions or other issues that I may have. Plus, my attending (as well as neurosurgeons, neurointerventional radiologists and other specialists) is ready to help with critical patients.

8:00 PM
A senior resident, assigned to the night float rotation, joins me for overnight call. As a two resident team, we take care of emergency neurology consultations, admissions and our neurology inpatients.
...........................................................................................................
US medical school fees are so high that...
....so high that the American Association of Medical Colleges (www.aamc.org) called on all American medical schools to mandate disability insurance coverage for all medical students.

Now, this is not a new fact - the call for the mandate was made way back in 2005 - but does highlight that these high medical school debts are tolerated only because the profession of medicine is highly paid. So, if this promise of a high income is suddenly lost due to a disability, the student lands in a hot boiling soup of soaring debts with unsure income.

How high are the fees ? Average medical student debt in America at the end of medical school is said to hover around $120,000 to $150,000

These high debts play a big role in explaining why American medical students are more prone to go for the higher paying fields like Radiology, Anesthesiology, Emergency Medicine - while leaving a void in the lower paying ones like Pediatrics, Family Medicine, Psychiatry, etc. ..which in turn makes these later fields easy to get in for the International Medical Graduate community.


Nurses Who Earn Like Physicians Almost
I started out in the Medical field as a nurse aid working under nurses in assisted living homes as means to finance my college education. Soon after I graduated with my B.S. in Biology I applied to PA school and got in. I since have graduated from the program and I am now getting ready to attend Medical School. When I was applying to PA school, at that time, I felt uncertain about my future. I knew I wanted to have a role in medicine, but I wasn’t sure where. I considered RN, but being a CNA for 4 years I learned their limitations. I wanted more responsibility. At the same time I didn’t want to spend all those years in school when I wasn’t 100% sure I wanted to retire in Medicine. So the best thing at the time was PA. I was attracted to the flexibility of the profession. If I didn’t like the job or I just got bored with the specialty I can change. That’s the way I felt at the time I was applying to PA school. As a PA student I was exposed to various aspects of medicine I didn’t know existed. I became good and excelled at what I did and I enjoyed it and now I have a passion for it. I want to reach the peak of my profession. I have PA friends who make $200,000 or more asking me what’s the point of going to Medical school when you can make as much as an MD with the education you have now. My answer is the Education. I want to excel in my profession. I want to be able to provide the pts I treat with the best medicine I can provide them with. As a PA student, we were trained along side with the Medical students. We took many of the same courses as well as the same exams. We were actually held to higher standards then the Medical students were. For example, on exams they were graded on a curve while we were not. But what I did notice is the level of education. The medical students go deeper, spend more time on subjects, and receive a richer education then we do. It was obvious when I went on my medical rotations. The PA student knew more about DX and treatment then the medical student, but the medical student knew more about the physiology and biology then we did. We received basic courses in those subjects, but not as in-depth. Having 20 years of experience working as a PA still does not equal the education that the doctors receive through medical school, residency, fellowship, and internship training. For the nurse who made a comment about working as an ER nurse for 20 yrs doesn’t mean you know as much as a doctor, PA, or NP who has only worked for 3 yrs. Their level of education far exceeds your experience. Is it feasible to say that a CNA working as a CNA for 20 years knows more then an RN with no experience? Hell no. I was a CNA, I know what they know and they know nothing. In the ER, you only see the clinical picture, but you don’t understand the biology, pathology, or physiology of what that pt is experiencing. Nor do you understand what the provider is ruling in / out when he is performing a physical exam. You don’t understand because you haven’t been trained in it. Having prior experience in any field is always good, but when you start NP school or Medical school, regardless of how many years of experience you have at your previous job, you will learn quick on how much you don’t know. And if you go into any new program thinking you know everything and not accepting the fact that you don’t know much, you will fail as a student and/or as a provider.

Texas PA-C

Physician Specialty Demand and Salary Trends for 2007
The Delta Companies offer staffing solutions for Physicians all over the USA and release yearly data on what physician specialties are hot and what the earning trends are. Here's a list of the physician specialties showing a trend for highest demand for the year 2007.

1. Internal Medicine
2. Orthopedics
3. Family Medicine
4. Cardiology
5. General Surgery
6. Hospitalist
7. Urology
8. Pulmonary Critical Care
9. Gastroenterology
10. Neurology
11. Ob-Gynecology
12. Radiology
13. Hematology / Oncology
14. Psychiatry
15. E.N.T.

How did these folks generate that list ? From the physician search requests they get from their tons of clients.

I am surprised that Pediatrics does not make it in these top-15 spots - either there are too many pediatricians around or the kids are getting better in health - or yeah - the family docs are looking after them ;-)

Download the Reports Here.


The First Quarter 2007 Reports also includes data on Starting Salary offers for various specialties. The figures that stood out were:

- Neurosurgery = $708,396 per Year
- Radiology = $608,684 per Year
- Orthopedics = $566,280 per Year

Hmmm...and according to this news report, the following specialties saw a rise in 2007 Starting salaries :

- E.N.T
- Pulmonary Critical care
- Psychiatry
- Orthopedic Surgery

The Following Specialties saw a decrease in average starting salaries:

- Oncology
- Anesthesiology

PhysicianDepot Survey: Physicians Paid Highest in Southern USA
PhysicianDepot announced the results of its nation-wide physicians survey and here are the features and observations that screamed for my attention :

1. Generally speaking the physicians in Southern US States are paid more, next in line are the mid-west doctors, and the states paying the physicians the least (as far as averages go) come out be the western states.

2. The highest Paid Specialties, often hovering above the $400,000 a year range, were the surgical ones - notably Neurosurgery, Cardiovascular Surgery, Interventional Cardiology and
Orthopedics

3. Primary Care stuck with the lowest doctor salaries as usual (Family Medicine, Internal Medicine, Pediatrics.etc)

4. Even Physical Medicine and Rehabilitation fared better than the primary care specialties

5. I now know that Radiation Oncology can pay above $250,000 a year ! Yeah - I can see a halo behind my mirror reflection ;-)

To see the salary Survey figures for yourself - Click here


The 20 top-paying jobs:

1. Chief executive officer: $1.18 Million
2. Chief operating officer: $690,219
3. Top-subsidiary executive: $624,831
4. Top-sector executive: $525,657
5. Top-division executive: $510,292
6. Intermediate corporate financial associate: $459,784
7. Heart transplant surgeon: $446,666
8. Cardiothoracic surgeon: $446,255
9. Top international executive: $425,839
10. Chief financial officer: $418,772
11. Top administrative executive: $410,335
12. Top legal executive: $404,235
13. Top mergers and acquisitions executive: $399,581
14. Top mortgage executive: $399,485
15. Top power trading executive: $391,911
16. Neurosurgeon: $386,906
17. Top investment executive: $386,148
18. Chief of surgery: $380,756
19. Senior corporate financial associate: $376,761
20. Top retail banking executive: $373,383

Will Radiologists Steal from the Gastroenterologist's Salary ?
Today, as in 2007, Gastroenterologists earn big dollars- thanks to the heavy volume of colonoscopies they perform for routine cancer screening, biopsies, followups and excisions. It is a "cash-cow" for them as we discussed on this blog earlier in the post on low Geriatrician incomes, since Medicare approved paying for all these screening colonoscopies since 2001.

However, a recent development threatens the source of these big bucks for Gastroenterologists - A study which showed that the non-invasive Virtual Colonoscopies that a Radiologist can perform are as effective as traditional invasive colonoscopies ! Read about that news Here and Here.

What do you think patients or even you and me are gonna prefer ? A tube up their hinds or a simple half-minute X-ray procedure ? And if Medicare decided that it would stop payment for the traditional optic colonoscopy and pay for the less dangerous, faster and possibly cheaper Virtual colonoscopy - Gastroenterologists lose ...a bit at least, since even if a polyp was virtually detected, a gastro doc would need to do a colonoscopy to get the sucker out.

Of course, I am talking extremes here - there will always be something else the Gastro MD will do - or maybe even take control of the Virtual Colonoscopy themselves ...just like the Cardiologsits invented "Interventional Radiology" to protect themselves from losing business to the Radiologists :-)


A great analysis appeared on the New York Times - Read that here.

It is interesting how it throws light on the constant political wars that go on between various medical specialties, at least in the US - Family Practitioners are 'at war' with the Internists, Interventional cardiologists with the Radiologists, Gynecologists with the Radiologists (Sonography issues) .etc.etc. ..in short, whenever areas of expertise overlap.

But even Radiologists had their way with this one - as Dr. Rex says on an NYtimes article:

"We have a lot of organs - the esophagus, the stomach, the small bowel, the liver, the pancreas. I think we’ve got a lot to do. Gastroenterologists will still be able to make a comfortable living"


America is an ageing population - "Baby Boomers" (Those born between 1946 to 1964), who represent the largest population group is fast approaching retirement age, and will start needed lotsa health care for chornic disease conditions like arthropathies, Ischemic Heart disease, Renal conditions, etc. Hence, naturally, Geriatrics - the medical specialty dealing with diseases of the aged, was supposed to be the next big thing in the US - well that was what was believed 2-3 years ago. But instead, geriatrics salaries have been found to be dismally low hovering near 160,000$ -170,000$ a year.

Geriatrics can be done as a Fellowship following either Family Practice or Internal Medicine. Following seem to be some of the reasons why pays have not seen increases:

- Family practioners and Internists already deal with a lot of Old patient diseases
- There are no specialized procedures that only Geriatricians are licensed to perform - I mean even Family practitioners do Colonoscopies, which pay !
- Medical students don't really have any special "Geriatric rotations"

One of the keys for docs in US to make more money is to do a lot of procedures, coz insurance companies pay well for those..as against consulting, examining and prescribing medicine. Every specialty will have some "cash cow" procedures to mint money from - like CABG for Cardiologists, Dialysis for Nephrologists, Colonoscopies for Family practitioners..and of course surgical branches like Orthopedics are full of procedures. As this 4th year medical student puts it, sticking a camera down someone's throat brings in more cash than spending an hour counseling and addressing the fears of a diabetic patient.


Read more about this on New York Times article: "Geriatrics Lags in the Age of High-Tech Medicine"

GERIATRICS AIN'T PAYING TOO MUCH
So how does the problem look in the Geriatric US ?

As per data from the American Geriatrics society, by 2030, the U.S. population age 65 and up will exceed 70 million, about double the number in 2000 - BUT - the number of geriatricians has decreased from 9,256 in 1998 to fewer than 7,000 in 2006. Current estimated need is about 14,000 geriatricians. By 2030, an estimated 36,000 will be needed.

I am guessing the US needs a better economic model for paying out physicians based on how much economic and health benefit they give the country rather than purely on the basis of how 'specialized' they are. Canada and UK are probably doing a better job, paying out the General and Family practitioners much more with new reforms in recognition of the great 'pyloric' or gate-keeping work the do for the health system. US needs to wake up to this.


TOP FIVE EARNING PHYSICIAN SPECIALTIES in USA (2006)
According to a recent survey conducted by the famous Modern Healthcare :

Orthopedic Surgeons stood at the top of the income ladder averaging a total cash earnings of around $403,000 in 2006. Incidentally, an Orthopedic specialist also registered the single-highest salary on the survery : about $489,000 !

Radiologists ranked second, with average pay of $394,000/-

Third came noninvasive cardiologists, at $370,000/-

Urologists held up the fourth spot averaging around $340,000/-

And the Anesthesiologists came up 5th with average salaries touching $333,000/-

Family practitioners continue to be at the bottom of the salary ladder averaging $165,000
Pediatricians were only about $100 higher than family practitioners, while Internists averaged about $177,000 in 2006 . However, Family Practitioner and Internists supposedly have seen the highest increase in salaries since the recent year, indicating a increase in demand in primary care and generalists !
Hmmmm....I wonder why cardiothoracic and Neurosurgeon Salaries do not feature in the top 5 ...

Yet, those were averages on top. They can get much higher as docs become senior within their organization or if they practice in a place of high demand and extremely low specialist supply - Check out this news article which speaks of $700,000/- salary for a cancer specialist in Montana and More than $200,000/- for a Nursing Director !

WHICH SPECIALTIES GET SUED THE MOST IN USA ?
"Being sued" in medical practice implies facing Malpractice litigation claims by patients seeking compensation from doctors for damages caused by either omission of good care or commission of bad care or both. The risk is very real for doctors in the US and many a times courts have awarded millions of dollars to the patients. Recently, this has been a cause of great concern to the country, since eventually, it increases the cost of healthcare in the US and people's taxes and health insurance premiums go up !

Being sued to the tune of gigantic dollars threatens to put a physician out of practice - this is why almost physicians in USA get themselves 'covered' by purchasing malpractice insurance.

Premiums i.e. the amount physicians have to pay each year to the protecting company, depend on the 'risk' of the specialty that the physician practices in. Here are the top specialties where doctor's get sued most often!


* Obstetrics - Gynecology
* Neurosurgery
* General Surgery
* Emergency medicine
* Orthopedic surgery
* Radiology
* Family Practice



Obstetrics-Gynecology presents with the highest risk of being sued by patients for malpractice and premiums that physicians must pay out of their own pockets can average $35,000 a year and sometimes much more in group / private practice ! According to Dr.Ronald Uva, chair of district II of the American College of Obstetricians and Gynecologists, liability premiums that ob-gyn docs must pay each year to cover themselves from losing their roofs in event of being sued, range from 40,000$ in upstate NY and a whopping $120,000/- in downstate ! Read more about it here.

Read this interesting article that says 76% Obstetricians get sued atleast once in the USA

State Variations in Premium rates are vast, often forcing doctors to pack bags and start up another practice in another state. For example I read about how Dr. Zimet left his orthopedic surgery practice in Pennsylvania after his yearly malpractice premiums hit $105,000/- and shifted to Virginia where the rates were $33,000 a year. Read the story Here.

The Golden Days are over...
but the silver is not too bad :-) Gone are the days when Physicians in the US could easily rake in more than a million dollars a year - thanks to the "Fee for Service" payment system that existed more than a decade ago. Under that system, the Insurance firms literally paid doctors for all that they billed their patients for. Then, you guessed right , the doctors overdid it - used up too many unnecessary services, kept patients for too long in the hospitals and earned their millions - while patient care quality suffered.

As insurance companies began to lose too much money and patients demanded better control on physician's quality of care - came the "Capitated payment systems" - the one that we are currently operating under. In this system, physicians /hospitals/ HMOs get a fixed total fee payment per diagnosis - a better term for which (you should know, since you will be working in the American Health System) is 'DRG' , or a Diagnosis Related Group. And, it is upto the physicians to keep their share from the total of what they get, after money has been spent on tests and Rx for the patient. So how do doctors make money and get competetive in such a scenario with tables turned ? Logical - they now do the opposite !! They try to reduce patients hospital stay (measured as Average Length of Stay - ALOS) , reduce unnecessary medical tests and save from patient care costs - so that they can get to keep a larger cut from the insurance payment. But at the same time, they cannot compromise on patient quality - thanks to the various accredidation programs and the newly launched public website that ranks patient care in hospitals.

This is why many physicians, who were used to the golden days, are grumpy about the new system that pays much less. However, the salaries are still not bad, when compared to those of the non-physician population. A good result of this need for quality improvement + Cost cutting has been a recent surge in the adoption of hospital information systems and technology like e-Prescription, Electronic Medical Records, Computerized Physician Order Entry Sytems, etc. to eliminate avoidable errors like misinterpreted medications, lost radiographs etc. and cut costs by eliminating paper, staff and automating many functions :-)

WHAT IS 'MOONLIGHTING'
For a Doc, it is never too dark to earn ...

The term refers to a physician slogging in the evenings [in the moonlight ;-)] for some extra $$ as a replacement for another physician. Do not confuse this with overtime - in moonlighting, physician A allows physician B to work his hours and gives physician B a 'cut' or a pre-agreed percentage of his pay. Whereas in overtime, physician A slogs extra hours as his own job !

This is typically done by junior physicians early in the game.

And just how much can a physician earn by moonlighting ? - A Cool additional 1000$-4000$ per week !

Having said that, it is usually easier for residents in primary care specialties (Internal Medicine, Family Medicine, Pediatrics, Psychiatry, Ob-Gyn) to find Moonlighting Opportunities than the specialists. Some residents and Fellows have been known to make as much as 30,000$ to 40,000$ a year more through Moonlighting - all depends on how much you wanna slog it out...

It was interesting to read that in Japan, moonlighting is banned for trainee doctors - Read here about how some trainee docs were found moonlighting and earning upto 30,000 to 80,000 yen a Month working part-time.


Read more about Moonlighting Rules (and for IMGs) Here.

DO PHYSICIANS / DOCTORS EARN TOO MUCH ?
This debate caught steam ever since people first felt the pinch of expensive health-care. There are many aspects that one may argue over.


1. Physicians do spend a LOT of time of their lives (12 - 18 years) through break-neck studies of pre-med, medical school, residencies and fellowships, competition and terrible expenses to be reach where they are. Arrite, agreed that this alone should not be a excuse for earning a lot.

2. But physicians are also an investment that society makes to heal itself , maintain productivity and stay healthy (I agree preventive care has not got adequate attention it deserves)

3. Physician salaries that are reported are never calibrated to 40-hour weeks - they mostly represent salaries for 60-hour weeks on an average, while salaries in other fields mostly are 40 - 45 hour weeks. So when salaries are compared, the hourly rates should be rather compared - thus a $150,000 per annum salary for 60-hour week family medicine would mean $100,000 per annum if the same physician worked 40-hours a week instead.

4. Physician Salaries are NOT the biggest factors for costly healthcare, in fact they have been dropping steadily ever since Managed Care came to the scene - the big drivers for Medical costs in USA are : a. Ever-improving Medical Technology and Research b. Expensive and New Drugs c. Bad health choices that people make (Smoking, Obesity, etc. and consequent Cancers, Heart Diseases) and d. Uninsured People [44 Million in US] ALL of which contribute to increasing Insurance Premiums and Out-of-pocket payments and if you will e. The million dollars salaries and profits that health insurance companies channelize the health care dollars into.

5. What physicians do also drives a huge portion of the economy and create jobs for a lot of people in the health care arena - Nurses, Health care managers, Physician Assistants, Hospital Clerks, etc.

True that they earn good and high, but their salaries pale in comparison the richest lawyers, sports people, Entertainers and CEOs who count their salaries and bonuses in Millions of Dollars.
According to this news article, "In 1978 the average corporate CEO earned 35 times more than the average worker; today (2007) he (and yes, occasionally she) earns 262 times as much"
Now that's serious opportunities lost with all that money going into a single pocket, instead if corporations were refrained from paying out such enormous salaries, they would mostly use that cash to expand operations, creating more jobs...well, just my two dollars [the world of 2 cents is gone..;-)]

And plus we have kids less than 20 years old making more than 2 Million Dollars a year! I seriously doubt if any of the 946 Billionaires in the world (as of 2006) are practicing physicians ;-)

But then - yeah ! The Jan 2007 McKinsey Report did find that Physicians in USA were paid way to high as compared to other industrialized nations - to be specific, the report said US doctors were paid 56 Billion Dollars in Excess income - Read more here.


Click Here to see the results of the Poll I ran on this blog about whether US doctors are overpaid