jac241

Definitely interesting. Only things I'd be concerned about when thinking about painting them with a racially biased admissions brush is that UCSF's class size is not large at 171 so a swing of 20% in 1 year is only 40 students. It would not be hard for me to believe that there are 40 Latino and black students who also scored 98%ile+ on the MCAT who equally "deserve" acceptance there, the med schools ranked #15-3ish all provide pretty much the same level of opportunity so the Asians missing from UCSF might have chosen a different top school. If it's a decline for 5 years straight I would be concerned about it but idk if 2 years is enough to state a trend.

Yeah for sure. Just wanted to lay out for other passerby's in the thread that there's nothing forcing people to take medication that they don't think is beneficial for them, or for people who've never seen someone in a frank manic episode that we're unnecessarily medicating all of the next DaVinci's or Einsteins.

Great and thought provoking example. I think you could argue there could be some genetic susceptibility to having a manic episode when placed under stressors like that, meaning potentially there's a relative with bipolar disorder or pretty severe major depressive disorder. I don't think most people would fall into a manic episode when placed in situations like that, but it is impossible to know. In my time rotating in the psych emergency department I saw someone with a similar presentation to Ola. No psychiatric history, stressful event happened, didn't sleep for a few days, came in in frank psychosis, treated with Seroquel, left the next day totally fine. Diagnosis given was brief reactive psychosis. Maybe the same happened for Ola Wong.

The patients benefit from the treatment significantly since a lot of time people who are manic are living recklessly, spending all their money, gambling, being hypersexual, trying drugs, getting into fights, committing crimes, tearing up their relationships, and the list goes on. The percent of people with bipolar disorder who die by suicide is 10-15%.

Patients who are hypomanic by definition aren't having marked impairments in social or occupational functioning and won't need to be hospitalized. There's nothing forcing someone who isn't currently on a psychiatric hold to take medication, so if they're taking it it's likely because they believe they're benefitting from it.

Because you want to help people and not hijack their reward systems to maximize ad revenue?

https://www.mdcalc.com/phq-9-patient-health-questionnaire-9 . You deserve to feel happy and enjoy life. Don't let a stigma about mental illness prevent you from getting treatment (therapy and/or antidepressants) if you feel like you could benefit.

Amen. Depression is a a feeling of worthless or loss of interest in things that is significant enough to negatively impact your life.

That's textbook major depressive disorder. How long would you let Jenna suffer out of principle? One month was too short a time for you, so what a year, two? She's not attending classes, crying all the time, sleeping more than usual. Why would you let depression ruin her future when we have effective treatment with a favorable side effect profile (CBT + SSRIs)? It's not an either/or situation. Doctors definitely counsel to increase exercise and get outside when starting treatment for depression. I don't think your strategy is very compassionate at all.

Are you suggesting that impotence is an invented ("medicalized") condition? I should start a physicians of hacker news blog... Prozac and premenstrual dysphoric disorder is a better example.

It'd probably be worth shooting professors in those departments at those schools an email to try to set up research with them during your summers. There's at least some chance they can take you on or there is a research program you can be a part of. You're motivated and interested in those topics so I suspect you will be able to teach yourself what a course at one of those schools would have taught you.

Like you said I think intrinsic motivation matters more than where you go. I went to a "shitty" (at least that's what CMU kids have said more than once to me to my face) school, University of Pittsburgh. I did fun research during undergrad and managed to get a job after graduating easily enough. At that job, different CMU graduates called me dumb for going to a public high school and university, uncultured, and literally laughed in my face when I said that I wanted to switch careers and be a surgeon. During med school interviews, a Harvard girl immediately turned around and stopped talking to me after she asked where I went to college. Now I'm in medical school at a ~40th ranked place (no not Harvard or Penn, shocker) well on my way to my career goals. I've done deep learning research at a top children's hospital and am scoring great on practice board exams.

I guess my point is that people will always find something to shit on you for, and the bias against lower ranked schools comes from above. The state schools like Penn State, OSU, Pitt, Michigan, Florida, Illinois etc. are enormous institutions that have a good amount of research going on and are definitely accessible to a motivated high school student. So if you don't get in to an Ivy League school, your opportunities aren't going to be limited as much as you think, and rejection is a great motivator.

M2 here. This site never gives doctors the benefit of the doubt and has some of the worst takes on the profession. Every thread where physicians get brought up you can count on someone saying they're overpaid, can EASILY be replaced by a google search, are using the AMA to limit the supply of doctors, etc. The AMA can't even prevent nurse practitioners from getting full practice authority to use their 500 hours of training to harm patients, how exactly are they limiting supply. For a site and a profession that values data and research so much, a lot of people on this site do zero research on the US and other countries' healthcare systems, how physicians and midlevels get paid, what factors are increasing healthcare costs before denigrating physicians as greedy and useless.

People just have no idea what goes into training a physician. Even after 2 full years of studying medicine I feel like I don't know anything, the field is that huge. I assume some of the bad takes are due to most people on this site being young and only ever interfacing with the healthcare system whenever they get strep throat. Sure someone can Google that you need to treat strep throat with antibiotics (maybe they'll even pick the right one!), but make sure to warn them about post strep glomerulonephritis. Oh what's that, and why do I need to warn them about that and not rheumatic fever...

Here are the swiss salaries - https://www.reddit.com/r/medicine/comments/a8t87g/swiss_phys... Most are the same as US. They pay anesthesiologists more, dermatologists less, gastroenterologists more, etc. Most are about the same as here. They also have universal healthcare.

Here is a chart for Australia: https://www.businessinsider.com.au/heres-how-much-money-aust... Hard to say how much they earn when working private as well. Anecdotes from the medicine subreddit suggest a lot.

Canada: https://www.cnbc.com/2018/03/06/canadian-doctor-protest-thei...

Medscape always sets the bar low when comparing US to other countries. I don't know why they do not include these ones. Here's the Medscape report that conveniently leaves these three countries off (wonder why): https://www.medscape.com/slideshow/2019-international-compen...

I'll try to find more sources for the other countries as I am interested as well.

220k is likely on the low side for PCP here. Offers coming in more around $250-270 range.

It's easy to point at physicians and say they're artificially limiting the number of physicians created but they are not. Residency spots are funded by Medicare and that is the limiting factor. The hospitals get paid 150k for each resident, pass 55k on to the resident as salary, and keep the rest. Hospitals could choose to pay for their own residency positions, but they don't because then Medicare wouldn't be willing to subsidise the spots anymore.

You could suggest we replace the high paid physicians with nurse practitioners or physician assistants but that is ignoring the fact that they are paid in the exact same way (and soon to be amount - executive order signed to equalize Medicare payments b/w midlevels and physicians) as physicians! If an NP or PA sees 25 patients in a day, they will bill for the exact same amount as a physician would. Additionally, the midlevels would order more tests and imaging on average than physicians, driving healthcare costs ever higher. There's a reason hospitals love midlevels so much and are helping to push for their independent practice. Each unnecessary test or CT scan is extra $$$ to the hospital.

Everyone loves to compare doctor salaries between the US and the UK, but they fail to compare the salaries for other professional roles. These kinds of jobs often pay the same 1.75-2x premium comparing the two countries. They also fail to compare doctor salaries with other countries like Canada, Switzerland, and Australia which also pay similar absolute amounts to physicians in the US. Doctor salaries are not the driving force of increased healthcare expenses in the US. Per unit of work, they're paid much less than they were in the late 90s. Here's a graph that shows one of the main culprits: https://i1.wp.com/investingdoc.com/wp-content/uploads/2017/0...

Call me crazy but software engineers are over paid. All they do is Google for answers on stack overflow and copy and paste the code. You used to need highly intelligent engineers who could hold all the APIs in their head at a minimum. Now you can just Google for the documentation.

Leaving a practice means rebuilding a patient census and practice at another location which makes it more difficult for many kinds of doctors to switch jobs. EM, anesthesia, radiology, and others that don't have their own patients do switch jobs more frequently.

Probably jealously about people working at places like this getting paid more and more - https://c8.alamy.com/comp/W9509T/a-billiard-table-a-table-te...

Versus people working here having their per unit value of work cut by Medicare to 62% of what it was in 1998: https://static01.nyt.com/images/2019/02/17/opinion/sunday/17...

Have got to say though software/data skills have been super useful for research projects, which are the fun part of medical school vs the absolute grind of pounding facts in.

Can corroborate. Schools care about GPA too much even in the face of work experience (most doctors on admission committees have never had another job..) + MCAT score. Median GPA is 5% of the grading in the US News research rankings and that matters a ton to the schools. Went from software to med school, now in my second year (4 since software). 3.67 GPA (bioinformatics)/ 3.55 BioChemMathPhysics GPA with 100th percentile MCAT. ~140 hrs clinical experience when I applied. 20 applications, 6 interviews, 4 waitlists (to rejection), 1 immediate post-interview rejection (screw you too NYU), 1 acceptance.

If you read about this CEO and are thinking about making the switch be very realistic with your chances, particularly about your GPA like parent post said. Without a 3.7+ you're going to have a tough time, and there's no guarantee that you won't spend 2+ years and get rejected. You'll have to overperform on the MCAT. Expect bias against your work experience (only software really). Whenever I said I used to be a software engineer you could see the light leave some of the interviewers eyes... Though if you're FAANG or another name-brand company I wouldn't expect the same.

I get that a heart attack hospitalization is expensive, $55k on average. The physician is not pocketing all of that $55k. They aren't the ones charging that, that is the hospital. The physician will get ~$1k of that (look below for the calculation). Please try to be charitable in your evaluation of my ability to reason here.

I'm not trying to change the topic from office visit to heart attack. I provided the RVU calculation for the outpatient visits. That is how much the physicians are getting paid. You said that physicians are making a couple hundred bucks of each outpatient visit, which I don't believe is accurate, and I provided the calculation of why I don't think that is accurate. The total cost of the visit can be $250, but the physician is not getting anywhere near that.

I don't think it's accurate to say that they will be able clear $1000/hr. There is additional time needed to document each patient (often equal to the amount of time seeing the patient). I think seeing 3 visits in that time is plausible, but the physician is not getting that whole $250 (which is the point I'm trying to make). The clinic revenue may be $750 for that hour, but that needs to cover all of the overhead, and the physician will get whatever is left.

Make sure you are looking for sources that compare how much the private insurance pays physicians compared to medicare in particular vs how much they pay hospitals compared to medicare. The numbers will be different.

The $53,384 is what the hospital charges for the heart attack. The physician only gets the wRVUs for the services they provide in the hospital (if they're employed), so the 12.56 wRVU for the cardiac revascularization + the admission history and physical (2.61 wRVU CPT 99222) however many days of progress notes (2.00 wRV 1x each day - CPT 99233) in the hospital and the discharge summary (1.28 wRVU - CPT 99238) they write for the patient. So if a patient got revascularized and were in the hospital for 4 days before being discharged that's 12.56 + 2.61 (admission day) + 2 * 2.00 (2 inpatient days) + 1.28 (discharge day) = 20.45 wRVUs for the admission = $737 for the physician for that hospitalization.

I'm trying to make the distinction here between how much the hospital gets paid vs. the physician who provided the care. It's not accurate to say the physician is making $53,384 for the heart attack hospitalization, that is what the hospital is charging. The physician may make ~$1000 for an admission like that. If the physician is self-employed or in a group, they will charge for the facility RVUs and malpractice RVUs as well, because they need to cover the overhead of having a clinic to see the patient after the hospitalization.

If your bill breaks down the overhead for the clinic separate from the physician charge, then I'll agree that the physician made the $250 straight cash, but I don't think that is in any way the average amount any kind of doctor will make off an outpatient visit. Look at what you're suggesting, that a physician makes $1000/hr * 2080 workable hours in a year (not likely a physician only works 40hrs a week..) = $2+ million a year.

You said physicians get paid a couple hundred bucks for each visit. I provided the source that says how much a physician gets paid by medicare for an established outpatient visit. An outpatient visit for a new patient (99203) is 1.42 wRVU + 1.48 facility RVU + 0.13 malpractice RVU = 2.14 RVUs = $109 for Medicare. A complex new visit (99205) is 3.17 wRVU + 2.40 facility RVU + 0.28 malpractice RVU = 5.85*36.06 = 210 dollars. The facility RVU is the amount given to pay for staff, rent, and other overhead. In general, if a physician is employed, they are getting just the wRVU for the visit.

For outpatient visits, this source says medicare pays 92% of what private insurance pays for established outpatient visits, and 80% overall https://money.cnn.com/2014/04/21/news/economy/medicare-docto... .

I am a US citizen who used to be a software engineer who now attends a US MD Medical school and I have student health insurance.

For the heart attack patient, it isn't the physician who is charging the huge amount. It's the hospital. The physician is only going to get a certain factor (somewhere between 1x - maybe 3x on the extreme end) of that $440 for the wRVUs.

No, the Stark Law prevents that (self referral, referring to another business the physician has a stake in) https://en.wikipedia.org/wiki/Stark_Law . Physicians are paid according to a fee schedule that decides how much each thing they do is worth. Each procedure or office visit is assigned a work Relative Value Unit, which is multiplied by a conversion factor ($36.0391 for Medicare) to determine how much a physician gets paid. Private insurance generally follows the Medicare RVU scale, and has an adjustment ~120-150% for the conversion factor (just a guess, only a student). This conversion factor was $36.6873 in 1998, so, adjusting for inflation, Medicare values each thing a physician does at 62% of what it did in 1998. I hate that most of my posts on this site are about this topic, but so many people on this site get it so wrong when it comes to how physicians are paid.

They don't make a couple hundred bucks. A 99213 established outpatient visit is worth 0.96 work RVUs * $36.0391 Medicare conversion factor = $34.59 for a standard outpatient visit. Even if you add the facility RVU = 0.48 + malpractice RVU 0.08 that is $54.78 for an outpatient visit. To make a couple hundred bucks, you need to do something like placing a stent for someone who is having a heart attack: CPT code 92941 - 12.31 work RVUs = $443.64.

All this information is available online. You can look up the physician fee schedule straight from the CMS. https://www.cms.gov/apps/physician-fee-schedule/search/searc... . Here are the cardiology codes - https://myheart.net/cardiology-coding-center/coronary-interv...

To add an additional data point, doing a heart transplant is 89.50 wRVU * 36.0391 = $3225. I don't think doctors are living as well as you think. CPT code 33945.

Saves me a ton of time in medical school vs trying to brute force the facts in. Plus it keeps things I learned over a year ago fresh so it has been very helpful for preparing for USMLE Step 1. Medicine might be an ideal case for this kind of learning though.

The desktop app is GPL and it's all backed by a Sqlite db so it's possible to reverse engineer.

I use the suspend card (or note) command for this. Press @ when your reviewing and it will suspend the card and you won't see it again.

Fair assessment. Any thoughts to what could work as an alternative? For it flaws, overwork being the main one, I think other parts of residency make sense. Every year you advance further in a system of graduated responsibility until you become an attending. It would be nice if it were easier to switch fields or programs, but the different specialties do take care of different organ systems with their own unique pathology and skills needed for each.

The poor population outcomes and lack of access to healthcare in America is shameful and disappointing. One of the big issues in my mind that comes from the debt is that it traps people who realize that they don't want to be doctors after they start medical school into the medical field. The other is that the debt loads are starting to exclude people from lower paying specialties (family medicine, pediatrics, infectious disease).

The training time between US and other countries ends up being more or less the same when you add the fact that their residencies tend to be a little longer than in the US (due to less hours). Here is a list from the UK: https://thesavvyimg.co.uk/how-long-is-specialty-training-in-.... Many of the surgical specialties that take 7-8 there take 5 here (urology, vascular surgery, etc.). So even if their pregraduate training is only 6 vs our 8, there are some specialties where it comes out to be a wash. There's also definitely hazing/long hours in some other countries as well. Here's an example of an Australian plastic surgery hopeful: https://mindbodymiko.com/the-ugly-side-of-becoming-a-surgeon...

I don't see why they shouldn't fund more CS and STEM spots and universities in general. They will probably see a good return on investment. AFAIK higher education is subsidized in other countries but I'm not super knowledgeable about that.

On second thought maybe it would make sense to only subsidize the residency programs that are financially unsustainable but necessary, like family medicine or non-subspecialty internal medicine. Downside to this could be that hospitals could choose to not have residents and exacerbate the physician shortage.

Compared to what's on levels.fyi, most specialties will earn less than software engineers. Only cardiologists, gastroenterologists, radiologists, anesthesiologists, and the surgical specialties will have a chance at out earning someone at FAANG.

I think it is because the government finds it valuable to have a well trained workforce to take care of its Medicare patients. Do you want physicians to pay for the opportunity to work for hospitals taking care of their patients?