Friday, January 13, 2017
Government employed physician—no thanks
Every health care system in the world is facing its fair share of challenges. Ageing populations, the exponential increase in chronic diseases such as heart disease and diabetes, expensive new treatments—all at a time when most countries desperately need to curtail rising health care costs to save their economies. At the two extremes we have fully public-funded (socialized) medicine versus entirely free-market (private) health care delivery systems. I've written previously about my own experiences working in a number of different environments including the UK, Australia and US—three countries with vastly different systems, and how the ideal probably resides somewhere in-between the two extremes. I don't think that a fully centralized system such as the United Kingdom's National Health Service (NHS) is something that any country should ever be aspiring to. As fair as it sounds—completely free health care at the point use—patients unfortunately don't always get the choice or service that they need in a top-heavy bureaucratic set up.
Looking at things from the physician's point of view, there are also many profound differences when it comes to working in these different health care systems. I took the decision over a decade ago to come to the United States to do my residency training, and wasn't too sure whether I would stay in the country afterwards. I was young, a foreign adventure beckoned, and I had no idea what would await me as I started my residency in Baltimore. All these years later, I'm very glad I took that decision to come here. One of the first things that struck me when I started working here, was just how free-spirited and independent-minded doctors in America appeared to be, compared to the (also very hard-working) doctors I had just left behind in the UK. They were more in control of their own destiny and weren't constantly lobbying the government for their next $1,000 pay raise. As much as health care and the medical profession may be changing, I still think that America's doctors have it very good compared to most other countries. That isn't to say that we shouldn't stand up and fight for the autonomy and working conditions we still desire, but merely to put things in perspective. Given the chance, if you reduced the barriers for entry (e.g. taking the USMLEs, doing residency training again), doctors from probably every single country in the world would come to this country in a heartbeat to practice medicine.
Let's consider the current situation in the United Kingdom. It made news here several months ago when thousands of “junior” doctors were striking. Unlike the US, “junior” in the UK also includes some very senior physicians who may still be below Attending level (in a country where it takes a lot longer to complete a medical residency). I've discussed the strike in more detail here, and what lessons U.S. doctors can draw from it.
I still have many physician friends in the UK at various levels of seniority, and not to put too fine a point on it—the vast majority of them are quite miserable in their profession. Much more so than any job dissatisfaction that exists here in the US. Over there, the government controls absolutely everything, and a random health minister with absolutely no experience in health care can make cut throat decisions and enforce mandates that have an immediate and dramatic effect on the frontlines. The loss of control and autonomy that results from a completely centralized health care system is staggering. In the United States, despite our well-publicized problems, doctors still enjoy a much greater choice of working conditions and contracts. There are a variety of different ways any physician can work and types health care organization they can work in. In the UK: there's only one. The NHS bureaucrats control how many Attending physician posts are created, and doctors are completely beholden to their decisions. The private sector is tiny. During training, doctors frequently have to keep moving every 6 months to different towns as they complete their residencies, a process that can easily last a decade. Pay scales are published online, and are generally the same wherever you go, plus or minus maybe a few thousand pounds according to how many “antisocial hours” you work. Interestingly, because of the quirks of this government pay-scale, the salary for a senior Registrar (equivalent to a final year resident) could actually be higher than an Attending!
If you ever look at social media patterns of physicians in the UK (and I say this not to belittle them, but merely to state a point), you will notice a very government-employee type European attitude, filled with highly left-leaning statements, articles, and resolves to fight for better pay and conditions via striking and other organized union action. I'm quite middle of the road when it comes to politics, but there is definitely a very palpable difference in physicians' attitudes on both sides of the Atlantic—a result of what naturally happens when one becomes a “government worker”.
A final huge and important difference between physicians in a public versus a more private free-enterprise system, is that those from the latter are generally much more creative, innovative and entrepreneurial. Working for the government can indeed be a total ambition-killer.
A close physician friend of mine in the UK summarized it really well recently when he said to me that having a sole-employer in any profession is “always bad news”. I agree profoundly. That's why I have no intention of ever being a full-time government employed physician again in a completely centralized health care system.
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Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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David Katz, MD
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Other blogs of note:
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
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One of the most popular anonymous blogs written by an emergency room physician.