national health

Ed extend. British citizen. In hurt for years. Private x-rays showed that he had virtually no hip joint. For years the British National Health function kept cancelling his consultations. Finally Ed had enough. He cashed in his life savings and paid $18,000 for the surgery himself.. from a private doctor. This is your future in the U. S when Hillary gets her way with national health care. bequeath also... Under Hillary’s first health compassionate plan. Ed Crane would have been thrown in jail if he had pulled that little stunt in this country. You’re asking for it folks. You want someone else to be responsible for your health care.. anyone but you. Trust me you’re gonna love it.” I don’t know about you but this is wrong and if we vote her into office we will undergo no one to blame but our selves All taxes are a “redistribution of wealth”. The Republicans redistribute from the lay class to the top. “The Republicans just presided over the biggest distribution of wealth upward since the 1920s and we all know what happened then.” - account Clinton Oct 30th. 2008 “We” won’t be voting her into office but there are some who will and if there are more of them than there are of us they will inflict her upon us all. I am not taking the blame for anyone who believes and votes for the idea that misery is fine if it’s shared by everyone. And yet polling shows that her support since her dismal appearance at the debate has not wavered. It is not Hillary that is supported by the Left but an ideology that sees Hillary as the vehicle of power. That ideology cares not one whit for honesty or integrity nor for a duplicitous response in a debate. As desire as they think she can win they’ll support her to the end. “A strict observance of the written laws is doubtless one of the high duties of a good citizen but it is not the highest. The laws of necessity of self-preservation of saving our country when in danger are of higher obligation. To lose our country by a scrupulous adherence to written law would be to lose the law itself with life liberty property and all those who are enjoying them with us; thus absurdly sacrificing the end to the means.” I said this on the Peter Paul go - if these charges stick she’s dead meat. But for them to stick would be near miraculous in light of how serious scandal rolls of a Democrat’s back. We only be to look at the lack of accountability in the Al Gore fundraising scandal or the Harry Reid real estate scandal to get an idea of how high the bar of evidence will undergo to be in order to hold Hillary accountable for this Peter Paul stuff. This DWARFS Jack Abramoff yet the media is thusfar silent. If the charges don’t stick it could be the very thing she needs to pound the final nail in the coffin of any wish to defeat her. She’s good at playing the persecuted victim when it counts. “A strict observance of the written laws is doubtless one of the high duties of a good citizen but it is not the highest. The laws of necessity of self-preservation of saving our country when in danger are of higher obligation. To suffer our country by a scrupulous adherence to written law would be to lose the law itself with life liberty property and all those who are enjoying them with us; thus absurdly sacrificing the end to the means.” Yes. No one has been forced to wait “[f]or years” because “the. National Health Service kept cancelling his consultations.” Because we don’t have a National Health Service thankfully. I said this on the Peter Paul go - if these charges stick she’s dead meat. But for them to fasten would be near miraculous in light of how serious scandal rolls of a Democrat’s back. We only need to look at the lack of accountability in the Al Gore fundraising scandal or the annoy Reid real estate scandal to get an idea of how high the bar of evidence will have to be in order to hold Hillary accountable for this Peter Paul stuff. This DWARFS bring up Abramoff yet the media is thusfar silent. If the charges don’t stick it could be the very thing she needs to pound the final attach in the coffin of any hope to defeat her. She’s good at playing the persecuted victim when it counts. For months. I’ve been watching signs that indicate the “implosion” of the Democrats. - Moveon’s failed contend on the US military.- Nutroot criticism of the Congress they elected.- The Democrat Congress distancing itself from the far left lunatics.- Dissension and frustration among the nutroots themselves.- Positive signs pointing towards victory against al qaeda.- Democrats impotent attacks against the President. - Hillary’s mounting scandals.- Dissension among MSM on supporting Hillary.- Democrat candidates mounting more aggressive and effective attacks against Hillary etc. These may seem minor to some. To me it represents a “receding tide” of popular support. As we confront the lies from the left the left responds sounding just like al qaeda! We are comfort one year from elections! It’s going to get uglier but sometimes medicine can be a bitter pill to consume. I stand by my “gut” feeling that Hillary is a detriment to the Democrat celebrate representing everything antithetical to “todays” Democrat celebrate. Hillary ordain be jettisoned and only THEN perhaps Democrats can claim integrity and ethics. Yes. No one has been forced to wait “[f]or years” because “the. National Health Service kept cancelling his consultations.” Because we don’t have a National Health Service thankfully. Americans spend double on the health care in comparison with what people in other industrialized countries do. Also the Americans have more trouble in seeing doctors and problems in paying the medical bills. The analyse was made on seven nations and it comprises 12,000 adults in Britain the United States. Germany. Canada. Netherlands. New Zealand and Australia. Only the U. S doesn’t have a universal health care system. The report published on the internet said that Americans spent in 2005 $6,697 per capita on healthcare while the other countries spent less than half of that: $3,326 in Canada. $3,128 in Australia. $ 2,343 in New Zealand and $3.128 in Australia. According to Reuters. Karen Davis president of the fund said: “The survey shows that in the U. S. we pay the price for having a fragmented health care system.” According to the survey Americans and Canadians go to emergency departments for routine issues. Davis said: “In the U. S. nearly two of five (37 percent) of all adults and 42 percent of those with chronic conditions had skipped medications not seen a doctor when egest or foregone recommended care in the past year because of costs—rates come up above all other countries.” Patients in the U. S.. Germany. New Zealand and Australia have waited less than a month for this kind of surgery while about 15 percent of patients in countries like UK or Canada have to wait more than six months. In UK waits dropped from 2001 when 28 percent reported waiting more than six months. Regarding the safety of the patient Americans have the highest reports of lab test errors and medical or medication errors. In the past two years one-third of U. S patients that presented chronic conditions reported a medical medication or test error. All taxes are a “redistribution of wealth”. The Republicans redistribute from the middle class to the top. “The Republicans just presided over the biggest distribution of wealth upward since the 1920s and we all know what happened then.” - Bill Clinton Oct 30th. 2008 There is no way those polls can be fixed and I undergo definitive create. After the last Republican debate the Fox poll had on line that clearly Ron Paul smoked the other candidates. Yeah and Dennis Kucinich will be the Dem nominee and instead of running against each other they will form the first Co-Presidency since the Bill and Hil show and each share 2 years a piece as POTUS and Veep. What a world. If E Spitzer gets Hil’s way they are looking at every ILLEGAL ALIEN in NY voting Dem. Oh and throw in Ex-Cons too. There is no way those polls can be fixed and I have definitive proof. After the last Republican debate the Fox poll had on lie that clearly Ron Paul smoked the other candidates. Yeah and Dennis Kucinich ordain be the Dem nominee and instead of running against each other they will create the first Co-Presidency since the Bill and Hil show and each overlap 2 years a piece as POTUS and Veep. What a world. If E Spitzer gets Hil’s way they are looking at every ILLEGAL ALIEN in NY voting Dem. Oh and throw in Ex-Cons too. New York is a solid Blue state and always has been. And driver’s licences undergo nothing to do with voting. More tin foil. All taxes are a “redistribution of wealth”. The Republicans redistribute from the middle class to the top. “The Republicans just presided over the biggest distribution of wealth upward since the 1920s and we all know what happened then.” - Bill Clinton Oct 30th. 2008 Americans spend double on the health care in comparison with what people in other industrialized countries do. Also the Americans have more affect in seeing doctors and problems in paying the medical bills. . To play the GW game back at you the Commonwealth Fund has a skin in the game. From their website (discussing the 2006 elections): Federal policies could build on and enhance those efforts. The pending reauthorization of the State Children’s Health Insurance schedule this year should focus attention on enhancing coverage and making sure that all children get off to a healthy start in life; priorities consider ensuring adequate funding setting quality standards and perhaps expanding coverage to additional low-income children and their parents. You can act a look at the contents of the report itself also. The dollars are adjusted to designate “Purchasing Power Parity” whatever the hell that is. And they are based on spending nationwide divided by population. IOW if a country does fewer heart transplants (or boob jobs) the national cost goes down and they look better in this paper. Which is exactly how National Health Care controls costs. You don’t treat a few hips or deliver quadruplets or treat cancer and costs stay in control. Another word for that is rationing. So all the doctors nurses and health care professionals will take cuts in pay to “work for the state”? Maybe we should look at shackling them to patient’s beds to keep them on the job? So all the doctors nurses and health care professionals will take cuts in pay to “work for the state”? Maybe we should be at shackling them to patient’s beds to keep them on the job? Apparently that is what the Democrats be; for the health care industry to work as efficiently proficiently accountably and streamlined as the rest of the federal government. :roll: “A strict observance of the written laws is doubtless one of the high duties of a good citizen but it is not the highest. The laws of necessity of self-preservation of saving our country when in danger are of higher obligation. To lose our country by a scrupulous adherence to written law would be to lose the law itself with life liberty property and all those who are enjoying them with us; thus absurdly sacrificing the end to the means.”

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The answer is that we have priced a medical education well beyond the reach of most middle-class students. In 2004 tuition and fees at a public medical school averaged $16,153. Students who attended a private school paid $32,588 according to published in The New England Journal of Medicine. The author. Dr. Gail Morrison. Vice Dean for Education at University of Pennsylvania School of Medicine tacks on $20,000 to $25,000 a year for living expenses books and equipment to calculate that the total cost of four years of medical education comes to a heady $140,000 for public schools and $225,000 for private schools. I’d add that in many American cities students would be hard-pressed to cover rent food clothing utilities and transportation for $20,000 a year—let alone books and equipment. In Canada by contrast a medical education is much more affordable. InQuebec province for example students paid a piddling $2,943 intuition last year—though admittedly this deal was available only toQuebecers. But elsewhere in Canada tuition averaged just $12,728—about25 percent less than Americans were paying to attend a public medicalschool back in 2004 and about 60 percent less than they laid out toattend a private school. As a result Canadian students are much more open to becoming primarycare physicians even though they know that internists earn lowersalaries than specialists. Granted in Canada the governmentdetermines the ratio of residencies for primary care versus specialties but students are willing to fill the spots. Canada is nowclose to its goal of having 50 percent of its physicians. In the U. S. where the Association of Medical Colleges stronglysupports free choice of specialty for students only about one-third ofmedical school graduates become primary care physicians. This isunderstandable: the average U. S student leaves med school with$130,000 in debt. Moreover unlike law or business students who enterthe workforce immediately after graduation and can begin to pay offtheir debt the average medical school graduate spends an additionalthree to six years in postgraduate training programs while interestcontinues to pile up. Meanwhile he is painfully aware of salarydifferentials: recent numbers show the average family doctor earning$146,000 while the typical invasive cardiologist brings home $400,000. And at the beginning of his career a family doctor can expect to earnmuch less—perhaps $100,000 before taxes. Little wonder then that the share of medical students pursuing careersin primary care has plummeted from 49 percent in 1997 to 37 percent in2003; over the same span the number gravitating toward careers inradiology orthopedics ophthalmology and dermatology. Yet we don’t need more dermatologists. But we do need more primary carephysicians. Decades of research done at Dartmouth University show thatwhen Americans see more family doctors and fewer specialists outcomesare better in large part because patients receive more preventive careand ongoing management of chronic diseases before they become serious.(I have previously written about this issue.) But it’s not just that the high cost of med school is leaving us withtoo many specialists and too few generalists. Spiraling tuition alsoexplains why middle-class and working-class Americans are notwell-represented in the profession. Keep in mind that only 20 percentof physicians come from the lowest three steps on that five-stepladder—which includes the third step where median-income families live. a recent national survey of under-represented students reveals that thecost of attending medical school was the number-one reason they did notapply. Meanwhile an Institute of Medicine report found that whileHispanics constitute 12 percent of the population they account foronly 3.5 percent of all physicians and though 1 in 8 Americans isblack fewer than 1 in 20 physicians is black. As Morrison observes:“Continuing this trend has far-reaching consequences for the nationalhealth care workforce which needs diverse physicians in order toaddress the needs of an increasingly heterogeneous patient population.” Of course low-income students could take out loans just the way moreaffluent students do. But if you are coming from a median-incomehousehold (with a joint income of roughly $50,000) it is easy to seehow the idea of being $130,000 in debt could seem terrifying. Afterall what if you married your wife became pregnant and you had tomove out of your tiny one-bedroom apartment just as you were beginningyour career? What if you and two fellow graduates opened a smallpractice—and discovered after a year that the three of you justcouldn’t make the overhead? More fledgling practices go under than onemight imagine. What if you gave birth to twins and realized that youneeded to take a nine-month sabbatical from your medical career? Howwould you continue paying off your debt? Students coming from families on the top step of the ladder have afinancial safety net. They know that in an emergency it is likelythat parents or grandparents will come forward with interest-free loansor a gift. Students from poorer families realize that they will be outthere alone with tens of thousands of dollars in loans. Finally—and perhaps most importantly—the sky-high cost of a medicaleducation creates a shallow applicant pool making it harder formedical schools to find the very best doctors. Schools after all arelooking for those rare individuals who are not only fiercelyintelligent but compassionate and committed to medicine as a serviceprofession. What a patient needs is both competence and kindness. Yet if medical schools are accepting one out of every two applicants,just how discriminating can they be? How often must they wind up takingstudents who are bright hard-working and ambitious enough to nail therequired GPA—but lack the imagination to understand that there is moreto being a doctor? A larger applicant pool—a pool that was both broaderand deeper—would be more likely to yield students who possess the rangeof talents needed to become an exceptional physician. When Morrison tries to find a solution to these problems she runs intoa brick wall. She suggests that the federal government needs to domore by expanding and protecting the National Health Service Corps LoanRepayment Program for example and broadening the tax-exempt status ofmedical scholarships. “But,” she acknowledges. “these initiatives maynot be top priorities for a government dealing with war in Iraq agrowing national debt and threats of terrorism.” But the truth is that in order to train students medical schools needto make enormous capital investments in the priciest newest medicaltechnologies. As a result the cost of educating a student can easilyoutstrip the tuition the school receives. And while academic medicalcenters have other sources of government funding many also providemore care for uninsured and Medicaid patients than the averagehospital. They’re in no position to slash tuition. Ideally the federal government would find the funds to offer far moregenerous scholarships to students willing to become primary carephysicians and practice in the areas where they are most needed forfour or five years after graduating. Many might well put down roots. As an alternative. Princeton economist Uwe Reinhardt has proposed an intriguing solution. In a “Health Affairs” article titled “”Reinhardt suggests that the government might create a “human capitalmarket in which medical students could borrow the funds needed to payfor their own medical education”—and pay off the debt gradually theway one pays off a mortgage. “A graduate’s indebtedness of say,$200,000 upon entry into medical practice could be fully amortizedover twenty-five years at an interest rate of 8 percent with annualpayments of about $18,700,” Reinhardt explains. "If the payments weremade tax-deductible as they should be the net burden on the physicianmight be no higher than half that amount. As Main Street enterprisegoes this is not an enormous debt-service burden.” [my emphasis] “If all physicians were forced to debt-finance the full cost of theirmedical education,” he continues. "then a public physician workforcepolicy might take the form simply of judiciously targeting tax-financedloan forgiveness to achieve certain desired social ends be it adesired ethnic or gender mix in the physician supply a desiredspecialty or spatial distribution of physicians or a desired deliveryof health services such as care provided below the physician’sopportunity costs (including uncompensated care.) In principle onecould even use the mechanism to modulate the overall size of thephysician workforce." “In effect,the policy would be a slight variant of the current ROTCprogram for the military or the National Health Service Corps forphysicians. These two programs prepay the cost of the student’s humancapital and then hope to collect on it through mandated subsequentservice. The program proposed here would force the student toaccumulate financial indebtedness first and forgive that debt only instep with actual service delivery.” Reinhardt admits that this would be “a radical departure fromconventional physician workforce policy in the United States and inother countries.” Though he notes that. “unlike the United States mostother countries do not treat health care as basically a privateconsumer good and medical practice as just another form of freeenterprise. Instead they tend to treat physicians as quasi civilservants with explicit social obligations.” Would such a program fly in the U. S.? It’s hard to imagine requiringall medical students to take out loans to finance their education.(Though the truth is that today only 20 percent pay cash fortuition—the other 80 percent go into debt.) Moreover the idea ofamortizing medical school loans like a mortgage over 25 years andmaking them tax-deductible is appealing. It means that young doctorswho are trying to start a career and a family won’t be as strapped asthey are today. And if the government “judiciously” targetedloan-forgiveness programs to achieve desired social ends we could hopeto have both primary care doctors and specialists more evenlydistributed around the country in the places where they are neededmost. This in turn could make universal health care more affordable. Reinhardt's proposal is just one scheme for financing the cost ofmedical education. But it’s provocative and should encourage us tobegin thinking about how to open the doors of our medical community toa larger group of applicants coming from a much broader spectrum ofsociety. Art Fouger. Russ and Chien- First. Art Fouger and Russ: As you point out medical school is no longer a sure road to wealth as it was at least for some specialties for a couple of decades. (Prior to the early 1960s most doctors were GPs and while they made a good living most were not extremely wealthy. It was only with the advent of the specialities and Medicare as well as private insuers paying fee for services that doctors' incomes began to climb. Beginning in the 1980s. Medicare began to pare back reimbursements. Then in the 1990s managed care began to cut into doctors' earnings. Meanwhile the cost of med school spiraled and while low-interest loans continued to be available scholarships became rare. Finally the possibility of further government regulation in the form of national health reform does mean that a doctor entering the profession today really can't know what shape his career will take. On the other hand if as you suggest this draws more altruists into the profession presumably that would be all to the good. But I'd like to see the financial obstacles removed. Students shouldn't be graduating with crushing levels of debt. A. C. Chien-- I find your post hard to follow. You write "Thanks in part to LBJ there was a big boom in MD schools 20 years ago creating over-capacity in medical schools until recently." First. LBJ wasn't president 20 years ago (1987). And what were seen as the excesses of his Medicare legislation had been addressed long before--particulary under Reagan (1980). Secondly I don't know what you mean by "over capacity" in medical schools. "Excess capacity" is probably what you're referring to--but what does "excess capacity in medical schools" mean? Too many places for the number of students applying? Too many medical schools? C. A. Chien- You wrote "sometimes the applicant pool is much larger. " I'm wondering where you got that information. The fact is that the record high reatio of applicants per place was 2.8 in the mid 1970s was tuition was much much lower and many more scholarships were available (tied to a student's willingness to work in underserved areas.) Since then the number of applicants has dropped. By 1987. The New York Times was reporting that "traditionally the ratio has been 2 to 1" and fewer students are applying each year to the University of Connecticut School of Medicine in Farmington and at the Yale School of Medicine in New Haven. Connecticut's two medical schools. Declining applications at UConn and Yale reflect a national trend that began about a decade ago. Applications to the nation's 127 medical schools totaled 27,923 this year; 31,323 last year and 32,893 in 1985 according to the Association of American Medical Colleges in Washington. This year. 15,725 places were available at medical schools nationwide,. So as you can see by 1987 a two to one ratio was the norm--and has continued to be the norm with some fluctuation. But it was only in the 1970s --when school was more affordable that it went as high as 2.8. And it's quite clear that lower tuition would mean not only a larger pool but more diversity. Look at the poll of under-represented students saying that the main reason they didn't apply was the cost. Older Medical school administrators also say that when they were in school med students came from many different classes. C. A. Chien- You wrote "sometimes the applicant pool is much larger. " I'm wondering where you got that information. The fact is that the record high reatio of applicants per place was 2.8 in the mid 1970s was tuition was much much lower and many more scholarships were available (tied to a student's willingness to work in underserved areas.) Since then the number of applicants has dropped. By 1987. The New York Times was reporting that "traditionally the ratio has been 2 to 1" and fewer students are applying each year to the University of Connecticut School of Medicine in Farmington and at the Yale School of Medicine in New Haven. Connecticut's two medical schools. Declining applications at UConn and Yale reflect a national trend that began about a decade ago. Applications to the nation's 127 medical schools totaled 27,923 this year; 31,323 last year and 32,893 in 1985 according to the Association of American Medical Colleges in Washington. This year. 15,725 places were available at medical schools nationwide,. So as you can see by 1987 a two to one ratio was the norm--and has continued to be the norm with some fluctuation. But it was only in the 1970s --when school was more affordable that it went as high as 2.8. And it's quite clear that lower tuition would mean not only a larger pool but more diversity. Look at the poll of under-represented students saying that the main reason they didn't apply was the cost. Older Medical school administrators also say that when they were in school med students came from many different classes. Again thank you for your comments. As usual the people posting here are making extremely thoughtful contributions to the thread and I appreciate it- K-- I agree that it's hard to apply to medical school unless you make up your mind to become pre-med by sopohmore year. But it's equally hard in Canada--the requirements are as stiff and it's very hard to go back and fill them after you have graduated. And even if you are pre-med with very good grades it's difficult to make the cut. (I have a friend in Ottawa whose son did take the required courses and applied two years in a row without getting in.) So the need to make the decision early in your college career doesn't explain why roughly twice as many Canadians apply for every space in their schools. Moreover the fact that in the U. S.. 60% of those who enter school come from famlies in the top quintile economically does suggest that cost is a major barrier here. (A wider spectrum of society applies to med school in Canada as well as in other countries where a medical education is largely subsidized.) I like Reinhardt's "mortgage" idea (with the payments tax deductible) because it makes paying off the loan doable--even for someone who doesn't have a financial safety net. And as with a mortgage inflation would make the payments smaller and smaller (as a percentage of income) over time. But I definitely agree with you that I don't see how we could "force" everyone into this system of financing their med school education. On the other hand. I think we could make a "mortgage" option attractive enough (particularly by forgiving all or part of the loan if the student chooses to go where he/she is most needed after graduation) that many students might choose it. And Congress might actually pass the legislation because after the inital outlay the program would begin to pay for itself as students paid back loans (or served in parts of the country where people are not getting enough preventive care and management of chronic diseases thus reducing the nation's total health care bill.) Finally you write: "It is becoming financially insupportable to provide Medicare/Medicaid services still see patients adequately and keep a practice afloat. One way or another market forces will correct." I agree that it is becoming almost impossible to make it as a primary care physician in many places. And I'm afraid that market forces are already correcting. Some primary care practices are going under. Many primary care docs are simply refusing to take Medicaid patients and at least in NYC many are beginnig to refuse Medicare patients. Thus. Medicare patients are joining Medicaid and the uninsured in the bottom tier of a two-tier health care system that in the end will be very costly for all of us. People who don't get timely care and chronic-disease management become very expensive patients later on. The solution. I think is three-fold: Medicaid reimbursements must be raised to meet Medicare reimbursements and both Medicare and Medicaid reimbursements must be raised for primary care family docs etc. Meanwhile. Medicare has to re-examine its coverage. Right now it's covering too many unnecessary often unproven and over-priced procedures. This means that some specialists will find their reimbursements cut--largely because they'll be doing fewer of these procedures. The Medicare Payment ADvisory Comission is already heading in this direction and I suspect that over the next 2 or 3 years. Congress will follow their recommendations largely because it won't have any choice. The only alternative,under current Medicare law is to slash physicians payments by 10% across the board. And that won't happen. Politically it's a non-starter and everyone realizes that an across-the- board cut is a crude tool. Finally to survive. I think primary care docs (and other docs) are going to have to join large multi-specialty group practices or work as hospitalists. The days of the solo-practioner are coming to an end. Given the cost of real estate wages for staff and the informtation technology that all doctors are eventually going to need solo-practice just isn't practical. In rural areas doctors may organize themselves into virtual networks clustered around the hospital where they refer patients. They may not share space but they'll use one back office to manage the business : (everyhthing from billing buying IT and training staff on IT to hiring a cleaning service answering service etc. and they'll share EMRS.) In the long run this will lead to better-co-ordinated higher quality care. Right now too many "Lone Rangers" are practicing medicine without anyone knowing what they are doing. Some are excellent; some are less than mediocre. If a group of doctors are all working with the same electronic medical record they will quickly realize if someone is consistently deviating from best practice guidelines. Brad--you write: "The wards reads like a chronic disease list of woe. .. It all gets back to disjointed care lack of routine health maintenance (patient or system driven). My point is. EOL [end-of life] and acute care is all tied together--it is the diabetic complications and related immunosuppression that put grandma in the ICU with MRSA to begin with." Chien-- The numbers you cite are for one year only. There tends to be a boom and bust cycle in med school admissions--depending on how much funding med schools are getting from Medicare. In any case whether it's 2.3 applicants per place or 2 applicants you and I are in agreement that we need a more diverse (and so by definition larger) pool of applicants. Joe Blow-- I agree that funding for NHSC needs to be restored. But I can't agree that dentists nurses nurse practioners shouldn't be included in the program. As you know an infection from an abscessed tooth can kill a person. And nurses and nurse practioners are essential for preventive care. That said. I don't see why the funding to include them has to come out of the funding needed for doctors. While there are excellent post-baccalaureate programs for those who want to take the premed science requirements after graduation the total number of students these programs supply is far less than that total number of applicants. Applying to medical school requires an early commitment -- often times as early as high school as good grades there will lead to admission to the good colleges that make medical school admissions easier. Most students must decide on medicine in their freshman or sophomore year to complete the requirements research and volunteer hours needed to convince admissions committees that they are good candidates. The MCAT that final stumbling block is an exam that requires at least a good month of preparation usually more. Isn't it possible then that the low rate of applicants in the US is also a result of massive self-selection that occurs in the years before application? A few friends of mine have wished out loud they had thought of being pre-med in college. They find too many roadblocks in the way of completing their requirements to try for it now. Even removing debt considerations will not improve the lack of primary care doctors in the US until they receive pay and respect at the same levels as specialists. It is becoming financially insupportable to provide Medicare/Medicaid services still see patients adequately and keep a practice afloat. One way or another market forces will correct. As for turning my medical school tuition into a mortgage I have to pay off -- I worked extremely hard the years before I applied to save so that I could pay half now half later through loans. Any system that forces us into that repayment is inherently flawed. Either procedural-based payment will end or the general physician will be edged out in favor of the mid-level provider. I don't see why we need to step in except in the case of slashing Medicare payments. Maggie. I admit about 600 patients per year and have tracked my top 10 DRGs for some time. My sample is representative of what you will find in most acute care hospitals. Taking into account some variation eg more sickle cell in urban AA populations for example the usual suspects pop up continuously. I want to clarify what you call "chronic diseases" vs "hospital/EOL care." They are indistinguishable. Almost universally you will find:1) Chest Pain2) CHF3) Asthma4) Diabetes uncontrolled5) GI Bleedetc. amongst all these folks. The wards reads like a chronic disease list of woe and is universally comprised of above again. HTN. DM etc. plus lung disease geriatric related problems (UTI/PNA) and slew of others you know well. It all gets back to disjointed care lack of routine health maintenance (patient or system driven) and everything else we all blog about. Barry-- I too would have no problem with primary care docs averaging $200,000 after say 4 years. We need to pay them more. As for alternative careers in Canada the one thing I can say is that since so many Canadians are far to the left of us a career in business may not be as appealing for some young people. Meanwhile. Canadians are quite proud of their health care system--proud of the solidarity it represents. Canadians have always been our poor cousins but this is one thing that many (not all) Canadians feel they have done better than us. So this may be another reason why Canadians are more eager to become doctors. In terms of whether most of the waste in our health care system occurs in hospitals. I'm not sure. But I do know that end-of-life care is not the biggest expense. The biggest chunk of our healthcare dollars is spent treating patients suffering from just 5 chronic diseaes: diabetes congestive heart failure astham coronary heart disease and depression. How much of that money is spent while patients are in the hospital (because we didn't do a good eough job managing the disease. I don't know.) But I do know that we spend so much on these diseases because people live with them for a very long time--so you're talking about years and years of bills. And by and large there is no cure. Barry-- I too would have no problem with primary care docs averaging $200,000 after say 4 years. We need to pay them more. As for alternative careers in Canada the one thing I can say is that since so many Canadians are far to the left of us a career in business may not be as appealing for some young people. Meanwhile. Canadians are quite proud of their health care system--proud of the solidarity it represents. Canadians have always been our poor cousins but this is one thing that many (not all) Canadians feel they have done better than us. So this may be another reason why Canadians are more eager to become doctors. In terms of whether most of the waste in our health care system occurs in hospitals. I'm not sure. But I do know that end-of-life care is not the biggest expense. The biggest chunk of our healthcare dollars is spent treating patients suffering from just 5 chronic diseaes: diabetes congestive heart failure astham coronary heart disease and depression. How much of that money is spent while patients are in the hospital (because we didn't do a good eough job managing the disease. I don't know.) But I do know that we spend so much on these diseases because people live with them for a very long time--so you're talking about years and years of bills. And by and large there is no cure. You frequently make the point that becoming a doctor is about more than money and that people who only care about how much money they can make should not go into medicine. I'm sure there are plenty of people who consciously choose a medical career with full knowledge that they could make considerably more in law or business. Opportunity costs are not irrelevant however even if medical school tuition were fully paid by taxpayers. After all to become a PCP requires four years of undergraduate education plus four years of medical school plus at least two years of internship and residency. At the same time one could become a pharmacist in six years total (four years of undergraduate school plus two years of pharmacy school) and go to work for one of the large retail drug chains or PBM's for about $40 per hour ($80K per year) plus health and retirement benefits plus regular hours and for those who want it the opportunity to work part time. As for the alternative of getting an MBA (two years) to pursue a business career or a law degree (three years of law school). I wonder what the comparable entry level salaries are in Canada for management track MBA's and lawyers joining the large corporate law firms as compared to U. S salaries. I would have no problem if PCP's made $200K on average after say five years of practice and if the typical specialist made $500K. I would be especially comfortable with this level of compensation if we had a system where all doctors and hospitals used interoperable electronic medical records medical disputes were settled in a fair objective and consistent manner (using health courts or arbitration but not lay juries) and we had a sensible approach to end of life. I saw an estimate on the Healthcare For All blog last week that suggested that fully 70% of the excess medical costs in the U. S vs the OECD average relate to care delivered in hospitals – both inpatient and outpatient. This is where end of life care is delivered. This is where the absence of interoperable electronic records lead to lots of duplicate testing and adverse drug interactions. This is where doctors often encounter patient they don't know (especially in ER's) and are most inclined to practice defensive medicine to minimize the chance of a lawsuit if there is an adverse outcome. So it's not doctors' salaries that are the problem. It's excess unnecessary and often unwanted utilization. Let's focus our cost reduction efforts there and on comparative effectiveness research and streamlining and simplifying insurance offerings. Maggie. I would encourage you to adjust your numbers a bit. If you figure with living expenses public schools in the $140K range and private schools in the $225K I am not sure how you got the average on the low end of that. I would also add that a pre-med four year education is required for medical school this also costs money and most people do not pay it off between school thus increasing the medical student's debt above that figured in your piece. Finally. I would add that I am personally from the lower middle class. (prior to med school I had jobs such as retreading tires cutting trees and fixing ski lifts) and this is how comming from no money effects debt. Most (if not all) of my school colleagues where from some money they didn't have to borrow extra to pay for many of those little things (travel home for christmas) gifts recreation etc. If I wanted those things in my life (most necessary for my psych) I had to borrow more my colleagues got it from mom and dad.

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The answer is that we have priced a medical education well beyond the reach of most middle-class students. In 2004 tuition and fees at a public medical school averaged $16,153. Students who attended a private school paid $32,588 according to published in The New England Journal of Medicine. The author. Dr. Gail Morrison. Vice Dean for Education at University of Pennsylvania School of Medicine tacks on $20,000 to $25,000 a year for living expenses books and equipment to calculate that the total cost of four years of medical education comes to a heady $140,000 for public schools and $225,000 for private schools. I’d add that in many American cities students would be hard-pressed to cover rent food clothing utilities and transportation for $20,000 a year—let alone books and equipment. In Canada by contrast a medical education is much more affordable. InQuebec province for example students paid a piddling $2,943 intuition last year—though admittedly this deal was available only toQuebecers. But elsewhere in Canada tuition averaged just $12,728—about25 percent less than Americans were paying to attend a public medicalschool back in 2004 and about 60 percent less than they laid out toattend a private school. As a result Canadian students are much more open to becoming primarycare physicians even though they know that internists earn lowersalaries than specialists. Granted in Canada the governmentdetermines the ratio of residencies for primary care versus specialties but students are willing to fill the spots. Canada is nowclose to its goal of having 50 percent of its physicians. In the U. S. where the Association of Medical Colleges stronglysupports free choice of specialty for students only about one-third ofmedical school graduates become primary care physicians. This isunderstandable: the average U. S student leaves med school with$130,000 in debt. Moreover unlike law or business students who enterthe workforce immediately after graduation and can begin to pay offtheir debt the average medical school graduate spends an additionalthree to six years in postgraduate training programs while interestcontinues to pile up. Meanwhile he is painfully aware of salarydifferentials: recent numbers show the average family doctor earning$146,000 while the typical invasive cardiologist brings home $400,000. And at the beginning of his career a family doctor can expect to earnmuch less—perhaps $100,000 before taxes. Little wonder then that the share of medical students pursuing careersin primary care has plummeted from 49 percent in 1997 to 37 percent in2003; over the same span the number gravitating toward careers inradiology orthopedics ophthalmology and dermatology. Yet we don’t need more dermatologists. But we do need more primary carephysicians. Decades of research done at Dartmouth University show thatwhen Americans see more family doctors and fewer specialists outcomesare better in large part because patients receive more preventive careand ongoing management of chronic diseases before they become serious.(I have previously written about this issue.) But it’s not just that the high cost of med school is leaving us withtoo many specialists and too few generalists. Spiraling tuition alsoexplains why middle-class and working-class Americans are notwell-represented in the profession. Keep in mind that only 20 percentof physicians come from the lowest three steps on that five-stepladder—which includes the third step where median-income families live. a recent national survey of under-represented students reveals that thecost of attending medical school was the number-one reason they did notapply. Meanwhile an Institute of Medicine report found that whileHispanics constitute 12 percent of the population they account foronly 3.5 percent of all physicians and though 1 in 8 Americans isblack fewer than 1 in 20 physicians is black. As Morrison observes:“Continuing this trend has far-reaching consequences for the nationalhealth care workforce which needs diverse physicians in order toaddress the needs of an increasingly heterogeneous patient population.” Of course low-income students could take out loans just the way moreaffluent students do. But if you are coming from a median-incomehousehold (with a joint income of roughly $50,000) it is easy to seehow the idea of being $130,000 in debt could seem terrifying. Afterall what if you married your wife became pregnant and you had tomove out of your tiny one-bedroom apartment just as you were beginningyour career? What if you and two fellow graduates opened a smallpractice—and discovered after a year that the three of you justcouldn’t make the overhead? More fledgling practices go under than onemight imagine. What if you gave birth to twins and realized that youneeded to take a nine-month sabbatical from your medical career? Howwould you continue paying off your debt? Students coming from families on the top step of the ladder have afinancial safety net. They know that in an emergency it is likelythat parents or grandparents will come forward with interest-free loansor a gift. Students from poorer families realize that they will be outthere alone with tens of thousands of dollars in loans. Finally—and perhaps most importantly—the sky-high cost of a medicaleducation creates a shallow applicant pool making it harder formedical schools to find the very best doctors. Schools after all arelooking for those rare individuals who are not only fiercelyintelligent but compassionate and committed to medicine as a serviceprofession. What a patient needs is both competence and kindness. Yet if medical schools are accepting one out of every two applicants,just how discriminating can they be? How often must they wind up takingstudents who are bright hard-working and ambitious enough to nail therequired GPA—but lack the imagination to understand that there is moreto being a doctor? A larger applicant pool—a pool that was both broaderand deeper—would be more likely to yield students who possess the rangeof talents needed to become an exceptional physician. When Morrison tries to find a solution to these problems she runs intoa brick wall. She suggests that the federal government needs to domore by expanding and protecting the National Health Service Corps LoanRepayment Program for example and broadening the tax-exempt status ofmedical scholarships. “But,” she acknowledges. “these initiatives maynot be top priorities for a government dealing with war in Iraq agrowing national debt and threats of terrorism.” But the truth is that in order to train students medical schools needto make enormous capital investments in the priciest newest medicaltechnologies. As a result the cost of educating a student can easilyoutstrip the tuition the school receives. And while academic medicalcenters have other sources of government funding many also providemore care for uninsured and Medicaid patients than the averagehospital. They’re in no position to slash tuition. Ideally the federal government would find the funds to offer far moregenerous scholarships to students willing to become primary carephysicians and practice in the areas where they are most needed forfour or five years after graduating. Many might well put down roots. As an alternative. Princeton economist Uwe Reinhardt has proposed an intriguing solution. In a “Health Affairs” article titled “”Reinhardt suggests that the government might create a “human capitalmarket in which medical students could borrow the funds needed to payfor their own medical education”—and pay off the debt gradually theway one pays off a mortgage. “A graduate’s indebtedness of say,$200,000 upon entry into medical practice could be fully amortizedover twenty-five years at an interest rate of 8 percent with annualpayments of about $18,700,” Reinhardt explains. "If the payments weremade tax-deductible as they should be the net burden on the physicianmight be no higher than half that amount. As Main Street enterprisegoes this is not an enormous debt-service burden.” [my emphasis] “If all physicians were forced to debt-finance the full cost of theirmedical education,” he continues. "then a public physician workforcepolicy might take the form simply of judiciously targeting tax-financedloan forgiveness to achieve certain desired social ends be it adesired ethnic or gender mix in the physician supply a desiredspecialty or spatial distribution of physicians or a desired deliveryof health services such as care provided below the physician’sopportunity costs (including uncompensated care.) In principle onecould even use the mechanism to modulate the overall size of thephysician workforce." “In effect,the policy would be a slight variant of the current ROTCprogram for the military or the National Health Service Corps forphysicians. These two programs prepay the cost of the student’s humancapital and then hope to collect on it through mandated subsequentservice. The program proposed here would force the student toaccumulate financial indebtedness first and forgive that debt only instep with actual service delivery.” Reinhardt admits that this would be “a radical departure fromconventional physician workforce policy in the United States and inother countries.” Though he notes that. “unlike the United States mostother countries do not treat health care as basically a privateconsumer good and medical practice as just another form of freeenterprise. Instead they tend to treat physicians as quasi civilservants with explicit social obligations.” Would such a program fly in the U. S.? It’s hard to imagine requiringall medical students to take out loans to finance their education.(Though the truth is that today only 20 percent pay cash fortuition—the other 80 percent go into debt.) Moreover the idea ofamortizing medical school loans like a mortgage over 25 years andmaking them tax-deductible is appealing. It means that young doctorswho are trying to start a career and a family won’t be as strapped asthey are today. And if the government “judiciously” targetedloan-forgiveness programs to achieve desired social ends we could hopeto have both primary care doctors and specialists more evenlydistributed around the country in the places where they are neededmost. This in turn could make universal health care more affordable. Reinhardt's proposal is just one scheme for financing the cost ofmedical education. But it’s provocative and should encourage us tobegin thinking about how to open the doors of our medical community toa larger group of applicants coming from a much broader spectrum ofsociety. Art Fouger. Russ and Chien- First. Art Fouger and Russ: As you point out medical school is no longer a sure road to wealth as it was at least for some specialties for a couple of decades. (Prior to the early 1960s most doctors were GPs and while they made a good living most were not extremely wealthy. It was only with the advent of the specialities and Medicare as well as private insuers paying fee for services that doctors' incomes began to climb. Beginning in the 1980s. Medicare began to pare back reimbursements. Then in the 1990s managed care began to cut into doctors' earnings. Meanwhile the cost of med school spiraled and while low-interest loans continued to be available scholarships became rare. Finally the possibility of further government regulation in the form of national health reform does mean that a doctor entering the profession today really can't know what shape his career will take. On the other hand if as you suggest this draws more altruists into the profession presumably that would be all to the good. But I'd like to see the financial obstacles removed. Students shouldn't be graduating with crushing levels of debt. A. C. Chien-- I find your post hard to follow. You write "Thanks in part to LBJ there was a big boom in MD schools 20 years ago creating over-capacity in medical schools until recently." First. LBJ wasn't president 20 years ago (1987). And what were seen as the excesses of his Medicare legislation had been addressed long before--particulary under Reagan (1980). Secondly I don't know what you mean by "over capacity" in medical schools. "Excess capacity" is probably what you're referring to--but what does "excess capacity in medical schools" mean? Too many places for the number of students applying? Too many medical schools? C. A. Chien- You wrote "sometimes the applicant pool is much larger. " I'm wondering where you got that information. The fact is that the record high reatio of applicants per place was 2.8 in the mid 1970s was tuition was much much lower and many more scholarships were available (tied to a student's willingness to work in underserved areas.) Since then the number of applicants has dropped. By 1987. The New York Times was reporting that "traditionally the ratio has been 2 to 1" and fewer students are applying each year to the University of Connecticut School of Medicine in Farmington and at the Yale School of Medicine in New Haven. Connecticut's two medical schools. Declining applications at UConn and Yale reflect a national trend that began about a decade ago. Applications to the nation's 127 medical schools totaled 27,923 this year; 31,323 last year and 32,893 in 1985 according to the Association of American Medical Colleges in Washington. This year. 15,725 places were available at medical schools nationwide,. So as you can see by 1987 a two to one ratio was the norm--and has continued to be the norm with some fluctuation. But it was only in the 1970s --when school was more affordable that it went as high as 2.8. And it's quite clear that lower tuition would mean not only a larger pool but more diversity. Look at the poll of under-represented students saying that the main reason they didn't apply was the cost. Older Medical school administrators also say that when they were in school med students came from many different classes. C. A. Chien- You wrote "sometimes the applicant pool is much larger. " I'm wondering where you got that information. The fact is that the record high reatio of applicants per place was 2.8 in the mid 1970s was tuition was much much lower and many more scholarships were available (tied to a student's willingness to work in underserved areas.) Since then the number of applicants has dropped. By 1987. The New York Times was reporting that "traditionally the ratio has been 2 to 1" and fewer students are applying each year to the University of Connecticut School of Medicine in Farmington and at the Yale School of Medicine in New Haven. Connecticut's two medical schools. Declining applications at UConn and Yale reflect a national trend that began about a decade ago. Applications to the nation's 127 medical schools totaled 27,923 this year; 31,323 last year and 32,893 in 1985 according to the Association of American Medical Colleges in Washington. This year. 15,725 places were available at medical schools nationwide,. So as you can see by 1987 a two to one ratio was the norm--and has continued to be the norm with some fluctuation. But it was only in the 1970s --when school was more affordable that it went as high as 2.8. And it's quite clear that lower tuition would mean not only a larger pool but more diversity. Look at the poll of under-represented students saying that the main reason they didn't apply was the cost. Older Medical school administrators also say that when they were in school med students came from many different classes. Again thank you for your comments. As usual the people posting here are making extremely thoughtful contributions to the thread and I appreciate it- K-- I agree that it's hard to apply to medical school unless you make up your mind to become pre-med by sopohmore year. But it's equally hard in Canada--the requirements are as stiff and it's very hard to go back and fill them after you have graduated. And even if you are pre-med with very good grades it's difficult to make the cut. (I have a friend in Ottawa whose son did take the required courses and applied two years in a row without getting in.) So the need to make the decision early in your college career doesn't explain why roughly twice as many Canadians apply for every space in their schools. Moreover the fact that in the U. S.. 60% of those who enter school come from famlies in the top quintile economically does suggest that cost is a major barrier here. (A wider spectrum of society applies to med school in Canada as well as in other countries where a medical education is largely subsidized.) I like Reinhardt's "mortgage" idea (with the payments tax deductible) because it makes paying off the loan doable--even for someone who doesn't have a financial safety net. And as with a mortgage inflation would make the payments smaller and smaller (as a percentage of income) over time. But I definitely agree with you that I don't see how we could "force" everyone into this system of financing their med school education. On the other hand. I think we could make a "mortgage" option attractive enough (particularly by forgiving all or part of the loan if the student chooses to go where he/she is most needed after graduation) that many students might choose it. And Congress might actually pass the legislation because after the inital outlay the program would begin to pay for itself as students paid back loans (or served in parts of the country where people are not getting enough preventive care and management of chronic diseases thus reducing the nation's total health care bill.) Finally you write: "It is becoming financially insupportable to provide Medicare/Medicaid services still see patients adequately and keep a practice afloat. One way or another market forces will correct." I agree that it is becoming almost impossible to make it as a primary care physician in many places. And I'm afraid that market forces are already correcting. Some primary care practices are going under. Many primary care docs are simply refusing to take Medicaid patients and at least in NYC many are beginnig to refuse Medicare patients. Thus. Medicare patients are joining Medicaid and the uninsured in the bottom tier of a two-tier health care system that in the end will be very costly for all of us. People who don't get timely care and chronic-disease management become very expensive patients later on. The solution. I think is three-fold: Medicaid reimbursements must be raised to meet Medicare reimbursements and both Medicare and Medicaid reimbursements must be raised for primary care family docs etc. Meanwhile. Medicare has to re-examine its coverage. Right now it's covering too many unnecessary often unproven and over-priced procedures. This means that some specialists will find their reimbursements cut--largely because they'll be doing fewer of these procedures. The Medicare Payment ADvisory Comission is already heading in this direction and I suspect that over the next 2 or 3 years. Congress will follow their recommendations largely because it won't have any choice. The only alternative,under current Medicare law is to slash physicians payments by 10% across the board. And that won't happen. Politically it's a non-starter and everyone realizes that an across-the- board cut is a crude tool. Finally to survive. I think primary care docs (and other docs) are going to have to join large multi-specialty group practices or work as hospitalists. The days of the solo-practioner are coming to an end. Given the cost of real estate wages for staff and the informtation technology that all doctors are eventually going to need solo-practice just isn't practical. In rural areas doctors may organize themselves into virtual networks clustered around the hospital where they refer patients. They may not share space but they'll use one back office to manage the business : (everyhthing from billing buying IT and training staff on IT to hiring a cleaning service answering service etc. and they'll share EMRS.) In the long run this will lead to better-co-ordinated higher quality care. Right now too many "Lone Rangers" are practicing medicine without anyone knowing what they are doing. Some are excellent; some are less than mediocre. If a group of doctors are all working with the same electronic medical record they will quickly realize if someone is consistently deviating from best practice guidelines. Brad--you write: "The wards reads like a chronic disease list of woe. .. It all gets back to disjointed care lack of routine health maintenance (patient or system driven). My point is. EOL [end-of life] and acute care is all tied together--it is the diabetic complications and related immunosuppression that put grandma in the ICU with MRSA to begin with." Chien-- The numbers you cite are for one year only. There tends to be a boom and bust cycle in med school admissions--depending on how much funding med schools are getting from Medicare. In any case whether it's 2.3 applicants per place or 2 applicants you and I are in agreement that we need a more diverse (and so by definition larger) pool of applicants. Joe Blow-- I agree that funding for NHSC needs to be restored. But I can't agree that dentists nurses nurse practioners shouldn't be included in the program. As you know an infection from an abscessed tooth can kill a person. And nurses and nurse practioners are essential for preventive care. That said. I don't see why the funding to include them has to come out of the funding needed for doctors. While there are excellent post-baccalaureate programs for those who want to take the premed science requirements after graduation the total number of students these programs supply is far less than that total number of applicants. Applying to medical school requires an early commitment -- often times as early as high school as good grades there will lead to admission to the good colleges that make medical school admissions easier. Most students must decide on medicine in their freshman or sophomore year to complete the requirements research and volunteer hours needed to convince admissions committees that they are good candidates. The MCAT that final stumbling block is an exam that requires at least a good month of preparation usually more. Isn't it possible then that the low rate of applicants in the US is also a result of massive self-selection that occurs in the years before application? A few friends of mine have wished out loud they had thought of being pre-med in college. They find too many roadblocks in the way of completing their requirements to try for it now. Even removing debt considerations will not improve the lack of primary care doctors in the US until they receive pay and respect at the same levels as specialists. It is becoming financially insupportable to provide Medicare/Medicaid services still see patients adequately and keep a practice afloat. One way or another market forces will correct. As for turning my medical school tuition into a mortgage I have to pay off -- I worked extremely hard the years before I applied to save so that I could pay half now half later through loans. Any system that forces us into that repayment is inherently flawed. Either procedural-based payment will end or the general physician will be edged out in favor of the mid-level provider. I don't see why we need to step in except in the case of slashing Medicare payments. Maggie. I admit about 600 patients per year and have tracked my top 10 DRGs for some time. My sample is representative of what you will find in most acute care hospitals. Taking into account some variation eg more sickle cell in urban AA populations for example the usual suspects pop up continuously. I want to clarify what you call "chronic diseases" vs "hospital/EOL care." They are indistinguishable. Almost universally you will find:1) Chest Pain2) CHF3) Asthma4) Diabetes uncontrolled5) GI Bleedetc. amongst all these folks. The wards reads like a chronic disease list of woe and is universally comprised of above again. HTN. DM etc. plus lung disease geriatric related problems (UTI/PNA) and slew of others you know well. It all gets back to disjointed care lack of routine health maintenance (patient or system driven) and everything else we all blog about. Barry-- I too would have no problem with primary care docs averaging $200,000 after say 4 years. We need to pay them more. As for alternative careers in Canada the one thing I can say is that since so many Canadians are far to the left of us a career in business may not be as appealing for some young people. Meanwhile. Canadians are quite proud of their health care system--proud of the solidarity it represents. Canadians have always been our poor cousins but this is one thing that many (not all) Canadians feel they have done better than us. So this may be another reason why Canadians are more eager to become doctors. In terms of whether most of the waste in our health care system occurs in hospitals. I'm not sure. But I do know that end-of-life care is not the biggest expense. The biggest chunk of our healthcare dollars is spent treating patients suffering from just 5 chronic diseaes: diabetes congestive heart failure astham coronary heart disease and depression. How much of that money is spent while patients are in the hospital (because we didn't do a good eough job managing the disease. I don't know.) But I do know that we spend so much on these diseases because people live with them for a very long time--so you're talking about years and years of bills. And by and large there is no cure. Barry-- I too would have no problem with primary care docs averaging $200,000 after say 4 years. We need to pay them more. As for alternative careers in Canada the one thing I can say is that since so many Canadians are far to the left of us a career in business may not be as appealing for some young people. Meanwhile. Canadians are quite proud of their health care system--proud of the solidarity it represents. Canadians have always been our poor cousins but this is one thing that many (not all) Canadians feel they have done better than us. So this may be another reason why Canadians are more eager to become doctors. In terms of whether most of the waste in our health care system occurs in hospitals. I'm not sure. But I do know that end-of-life care is not the biggest expense. The biggest chunk of our healthcare dollars is spent treating patients suffering from just 5 chronic diseaes: diabetes congestive heart failure astham coronary heart disease and depression. How much of that money is spent while patients are in the hospital (because we didn't do a good eough job managing the disease. I don't know.) But I do know that we spend so much on these diseases because people live with them for a very long time--so you're talking about years and years of bills. And by and large there is no cure. You frequently make the point that becoming a doctor is about more than money and that people who only care about how much money they can make should not go into medicine. I'm sure there are plenty of people who consciously choose a medical career with full knowledge that they could make considerably more in law or business. Opportunity costs are not irrelevant however even if medical school tuition were fully paid by taxpayers. After all to become a PCP requires four years of undergraduate education plus four years of medical school plus at least two years of internship and residency. At the same time one could become a pharmacist in six years total (four years of undergraduate school plus two years of pharmacy school) and go to work for one of the large retail drug chains or PBM's for about $40 per hour ($80K per year) plus health and retirement benefits plus regular hours and for those who want it the opportunity to work part time. As for the alternative of getting an MBA (two years) to pursue a business career or a law degree (three years of law school). I wonder what the comparable entry level salaries are in Canada for management track MBA's and lawyers joining the large corporate law firms as compared to U. S salaries. I would have no problem if PCP's made $200K on average after say five years of practice and if the typical specialist made $500K. I would be especially comfortable with this level of compensation if we had a system where all doctors and hospitals used interoperable electronic medical records medical disputes were settled in a fair objective and consistent manner (using health courts or arbitration but not lay juries) and we had a sensible approach to end of life. I saw an estimate on the Healthcare For All blog last week that suggested that fully 70% of the excess medical costs in the U. S vs the OECD average relate to care delivered in hospitals – both inpatient and outpatient. This is where end of life care is delivered. This is where the absence of interoperable electronic records lead to lots of duplicate testing and adverse drug interactions. This is where doctors often encounter patient they don't know (especially in ER's) and are most inclined to practice defensive medicine to minimize the chance of a lawsuit if there is an adverse outcome. So it's not doctors' salaries that are the problem. It's excess unnecessary and often unwanted utilization. Let's focus our cost reduction efforts there and on comparative effectiveness research and streamlining and simplifying insurance offerings. Maggie. I would encourage you to adjust your numbers a bit. If you figure with living expenses public schools in the $140K range and private schools in the $225K I am not sure how you got the average on the low end of that. I would also add that a pre-med four year education is required for medical school this also costs money and most people do not pay it off between school thus increasing the medical student's debt above that figured in your piece. Finally. I would add that I am personally from the lower middle class. (prior to med school I had jobs such as retreading tires cutting trees and fixing ski lifts) and this is how comming from no money effects debt. Most (if not all) of my school colleagues where from some money they didn't have to borrow extra to pay for many of those little things (travel home for christmas) gifts recreation etc. If I wanted those things in my life (most necessary for my psych) I had to borrow more my colleagues got it from mom and dad.

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The answer is that we have priced a medical education well beyond the reach of most middle-class students. In 2004 tuition and fees at a public medical school averaged $16,153. Students who attended a private school paid $32,588 according to published in The New England Journal of Medicine. The author. Dr. Gail Morrison. Vice Dean for Education at University of Pennsylvania School of Medicine tacks on $20,000 to $25,000 a year for living expenses books and equipment to calculate that the total cost of four years of medical education comes to a heady $140,000 for public schools and $225,000 for private schools. I’d add that in many American cities students would be hard-pressed to cover rent food clothing utilities and transportation for $20,000 a year—let alone books and equipment. In Canada by contrast a medical education is much more affordable. InQuebec province for example students paid a piddling $2,943 intuition last year—though admittedly this deal was available only toQuebecers. But elsewhere in Canada tuition averaged just $12,728—about25 percent less than Americans were paying to attend a public medicalschool back in 2004 and about 60 percent less than they laid out toattend a private school. As a result Canadian students are much more open to becoming primarycare physicians even though they know that internists earn lowersalaries than specialists. Granted in Canada the governmentdetermines the ratio of residencies for primary care versus specialties but students are willing to fill the spots. Canada is nowclose to its goal of having 50 percent of its physicians. In the U. S. where the Association of Medical Colleges stronglysupports free choice of specialty for students only about one-third ofmedical school graduates become primary care physicians. This isunderstandable: the average U. S student leaves med school with$130,000 in debt. Moreover unlike law or business students who enterthe workforce immediately after graduation and can begin to pay offtheir debt the average medical school graduate spends an additionalthree to six years in postgraduate training programs while interestcontinues to pile up. Meanwhile he is painfully aware of salarydifferentials: recent numbers show the average family doctor earning$146,000 while the typical invasive cardiologist brings home $400,000. And at the beginning of his career a family doctor can expect to earnmuch less—perhaps $100,000 before taxes. Little wonder then that the share of medical students pursuing careersin primary care has plummeted from 49 percent in 1997 to 37 percent in2003; over the same span the number gravitating toward careers inradiology orthopedics ophthalmology and dermatology. Yet we don’t need more dermatologists. But we do need more primary carephysicians. Decades of research done at Dartmouth University show thatwhen Americans see more family doctors and fewer specialists outcomesare better in large part because patients receive more preventive careand ongoing management of chronic diseases before they become serious.(I have previously written about this issue.) But it’s not just that the high cost of med school is leaving us withtoo many specialists and too few generalists. Spiraling tuition alsoexplains why middle-class and working-class Americans are notwell-represented in the profession. Keep in mind that only 20 percentof physicians come from the lowest three steps on that five-stepladder—which includes the third step where median-income families live. a recent national survey of under-represented students reveals that thecost of attending medical school was the number-one reason they did notapply. Meanwhile an Institute of Medicine report found that whileHispanics constitute 12 percent of the population they account foronly 3.5 percent of all physicians and though 1 in 8 Americans isblack fewer than 1 in 20 physicians is black. As Morrison observes:“Continuing this trend has far-reaching consequences for the nationalhealth care workforce which needs diverse physicians in order toaddress the needs of an increasingly heterogeneous patient population.” Of course low-income students could take out loans just the way moreaffluent students do. But if you are coming from a median-incomehousehold (with a joint income of roughly $50,000) it is easy to seehow the idea of being $130,000 in debt could seem terrifying. Afterall what if you married your wife became pregnant and you had tomove out of your tiny one-bedroom apartment just as you were beginningyour career? What if you and two fellow graduates opened a smallpractice—and discovered after a year that the three of you justcouldn’t make the overhead? More fledgling practices go under than onemight imagine. What if you gave birth to twins and realized that youneeded to take a nine-month sabbatical from your medical career? Howwould you continue paying off your debt? Students coming from families on the top step of the ladder have afinancial safety net. They know that in an emergency it is likelythat parents or grandparents will come forward with interest-free loansor a gift. Students from poorer families realize that they will be outthere alone with tens of thousands of dollars in loans. Finally—and perhaps most importantly—the sky-high cost of a medicaleducation creates a shallow applicant pool making it harder formedical schools to find the very best doctors. Schools after all arelooking for those rare individuals who are not only fiercelyintelligent but compassionate and committed to medicine as a serviceprofession. What a patient needs is both competence and kindness. Yet if medical schools are accepting one out of every two applicants,just how discriminating can they be? How often must they wind up takingstudents who are bright hard-working and ambitious enough to nail therequired GPA—but lack the imagination to understand that there is moreto being a doctor? A larger applicant pool—a pool that was both broaderand deeper—would be more likely to yield students who possess the rangeof talents needed to become an exceptional physician. When Morrison tries to find a solution to these problems she runs intoa brick wall. She suggests that the federal government needs to domore by expanding and protecting the National Health Service Corps LoanRepayment Program for example and broadening the tax-exempt status ofmedical scholarships. “But,” she acknowledges. “these initiatives maynot be top priorities for a government dealing with war in Iraq agrowing national debt and threats of terrorism.” But the truth is that in order to train students medical schools needto make enormous capital investments in the priciest newest medicaltechnologies. As a result the cost of educating a student can easilyoutstrip the tuition the school receives. And while academic medicalcenters have other sources of government funding many also providemore care for uninsured and Medicaid patients than the averagehospital. They’re in no position to slash tuition. Ideally the federal government would find the funds to offer far moregenerous scholarships to students willing to become primary carephysicians and practice in the areas where they are most needed forfour or five years after graduating. Many might well put down roots. As an alternative. Princeton economist Uwe Reinhardt has proposed an intriguing solution. In a “Health Affairs” article titled “”Reinhardt suggests that the government might create a “human capitalmarket in which medical students could borrow the funds needed to payfor their own medical education”—and pay off the debt gradually theway one pays off a mortgage. “A graduate’s indebtedness of say,$200,000 upon entry into medical practice could be fully amortizedover twenty-five years at an interest rate of 8 percent with annualpayments of about $18,700,” Reinhardt explains. "If the payments weremade tax-deductible as they should be the net burden on the physicianmight be no higher than half that amount. As Main Street enterprisegoes this is not an enormous debt-service burden.” [my emphasis] “If all physicians were forced to debt-finance the full cost of theirmedical education,” he continues. "then a public physician workforcepolicy might take the form simply of judiciously targeting tax-financedloan forgiveness to achieve certain desired social ends be it adesired ethnic or gender mix in the physician supply a desiredspecialty or spatial distribution of physicians or a desired deliveryof health services such as care provided below the physician’sopportunity costs (including uncompensated care.) In principle onecould even use the mechanism to modulate the overall size of thephysician workforce." “In effect,the policy would be a slight variant of the current ROTCprogram for the military or the National Health Service Corps forphysicians. These two programs prepay the cost of the student’s humancapital and then hope to collect on it through mandated subsequentservice. The program proposed here would force the student toaccumulate financial indebtedness first and forgive that debt only instep with actual service delivery.” Reinhardt admits that this would be “a radical departure fromconventional physician workforce policy in the United States and inother countries.” Though he notes that. “unlike the United States mostother countries do not treat health care as basically a privateconsumer good and medical practice as just another form of freeenterprise. Instead they tend to treat physicians as quasi civilservants with explicit social obligations.” Would such a program fly in the U. S.? It’s hard to imagine requiringall medical students to take out loans to finance their education.(Though the truth is that today only 20 percent pay cash fortuition—the other 80 percent go into debt.) Moreover the idea ofamortizing medical school loans like a mortgage over 25 years andmaking them tax-deductible is appealing. It means that young doctorswho are trying to start a career and a family won’t be as strapped asthey are today. And if the government “judiciously” targetedloan-forgiveness programs to achieve desired social ends we could hopeto have both primary care doctors and specialists more evenlydistributed around the country in the places where they are neededmost. This in turn could make universal health care more affordable. Reinhardt's proposal is just one scheme for financing the cost ofmedical education. But it’s provocative and should encourage us tobegin thinking about how to open the doors of our medical community toa larger group of applicants coming from a much broader spectrum ofsociety. Art Fouger. Russ and Chien- First. Art Fouger and Russ: As you point out medical school is no longer a sure road to wealth as it was at least for some specialties for a couple of decades. (Prior to the early 1960s most doctors were GPs and while they made a good living most were not extremely wealthy. It was only with the advent of the specialities and Medicare as well as private insuers paying fee for services that doctors' incomes began to climb. Beginning in the 1980s. Medicare began to pare back reimbursements. Then in the 1990s managed care began to cut into doctors' earnings. Meanwhile the cost of med school spiraled and while low-interest loans continued to be available scholarships became rare. Finally the possibility of further government regulation in the form of national health reform does mean that a doctor entering the profession today really can't know what shape his career will take. On the other hand if as you suggest this draws more altruists into the profession presumably that would be all to the good. But I'd like to see the financial obstacles removed. Students shouldn't be graduating with crushing levels of debt. A. C. Chien-- I find your post hard to follow. You write "Thanks in part to LBJ there was a big boom in MD schools 20 years ago creating over-capacity in medical schools until recently." First. LBJ wasn't president 20 years ago (1987). And what were seen as the excesses of his Medicare legislation had been addressed long before--particulary under Reagan (1980). Secondly I don't know what you mean by "over capacity" in medical schools. "Excess capacity" is probably what you're referring to--but what does "excess capacity in medical schools" mean? Too many places for the number of students applying? Too many medical schools? C. A. Chien- You wrote "sometimes the applicant pool is much larger. " I'm wondering where you got that information. The fact is that the record high reatio of applicants per place was 2.8 in the mid 1970s was tuition was much much lower and many more scholarships were available (tied to a student's willingness to work in underserved areas.) Since then the number of applicants has dropped. By 1987. The New York Times was reporting that "traditionally the ratio has been 2 to 1" and fewer students are applying each year to the University of Connecticut School of Medicine in Farmington and at the Yale School of Medicine in New Haven. Connecticut's two medical schools. Declining applications at UConn and Yale reflect a national trend that began about a decade ago. Applications to the nation's 127 medical schools totaled 27,923 this year; 31,323 last year and 32,893 in 1985 according to the Association of American Medical Colleges in Washington. This year. 15,725 places were available at medical schools nationwide,. So as you can see by 1987 a two to one ratio was the norm--and has continued to be the norm with some fluctuation. But it was only in the 1970s --when school was more affordable that it went as high as 2.8. And it's quite clear that lower tuition would mean not only a larger pool but more diversity. Look at the poll of under-represented students saying that the main reason they didn't apply was the cost. Older Medical school administrators also say that when they were in school med students came from many different classes. C. A. Chien- You wrote "sometimes the applicant pool is much larger. " I'm wondering where you got that information. The fact is that the record high reatio of applicants per place was 2.8 in the mid 1970s was tuition was much much lower and many more scholarships were available (tied to a student's willingness to work in underserved areas.) Since then the number of applicants has dropped. By 1987. The New York Times was reporting that "traditionally the ratio has been 2 to 1" and fewer students are applying each year to the University of Connecticut School of Medicine in Farmington and at the Yale School of Medicine in New Haven. Connecticut's two medical schools. Declining applications at UConn and Yale reflect a national trend that began about a decade ago. Applications to the nation's 127 medical schools totaled 27,923 this year; 31,323 last year and 32,893 in 1985 according to the Association of American Medical Colleges in Washington. This year. 15,725 places were available at medical schools nationwide,. So as you can see by 1987 a two to one ratio was the norm--and has continued to be the norm with some fluctuation. But it was only in the 1970s --when school was more affordable that it went as high as 2.8. And it's quite clear that lower tuition would mean not only a larger pool but more diversity. Look at the poll of under-represented students saying that the main reason they didn't apply was the cost. Older Medical school administrators also say that when they were in school med students came from many different classes. Again thank you for your comments. As usual the people posting here are making extremely thoughtful contributions to the thread and I appreciate it- K-- I agree that it's hard to apply to medical school unless you make up your mind to become pre-med by sopohmore year. But it's equally hard in Canada--the requirements are as stiff and it's very hard to go back and fill them after you have graduated. And even if you are pre-med with very good grades it's difficult to make the cut. (I have a friend in Ottawa whose son did take the required courses and applied two years in a row without getting in.) So the need to make the decision early in your college career doesn't explain why roughly twice as many Canadians apply for every space in their schools. Moreover the fact that in the U. S.. 60% of those who enter school come from famlies in the top quintile economically does suggest that cost is a major barrier here. (A wider spectrum of society applies to med school in Canada as well as in other countries where a medical education is largely subsidized.) I like Reinhardt's "mortgage" idea (with the payments tax deductible) because it makes paying off the loan doable--even for someone who doesn't have a financial safety net. And as with a mortgage inflation would make the payments smaller and smaller (as a percentage of income) over time. But I definitely agree with you that I don't see how we could "force" everyone into this system of financing their med school education. On the other hand. I think we could make a "mortgage" option attractive enough (particularly by forgiving all or part of the loan if the student chooses to go where he/she is most needed after graduation) that many students might choose it. And Congress might actually pass the legislation because after the inital outlay the program would begin to pay for itself as students paid back loans (or served in parts of the country where people are not getting enough preventive care and management of chronic diseases thus reducing the nation's total health care bill.) Finally you write: "It is becoming financially insupportable to provide Medicare/Medicaid services still see patients adequately and keep a practice afloat. One way or another market forces will correct." I agree that it is becoming almost impossible to make it as a primary care physician in many places. And I'm afraid that market forces are already correcting. Some primary care practices are going under. Many primary care docs are simply refusing to take Medicaid patients and at least in NYC many are beginnig to refuse Medicare patients. Thus. Medicare patients are joining Medicaid and the uninsured in the bottom tier of a two-tier health care system that in the end will be very costly for all of us. People who don't get timely care and chronic-disease management become very expensive patients later on. The solution. I think is three-fold: Medicaid reimbursements must be raised to meet Medicare reimbursements and both Medicare and Medicaid reimbursements must be raised for primary care family docs etc. Meanwhile. Medicare has to re-examine its coverage. Right now it's covering too many unnecessary often unproven and over-priced procedures. This means that some specialists will find their reimbursements cut--largely because they'll be doing fewer of these procedures. The Medicare Payment ADvisory Comission is already heading in this direction and I suspect that over the next 2 or 3 years. Congress will follow their recommendations largely because it won't have any choice. The only alternative,under current Medicare law is to slash physicians payments by 10% across the board. And that won't happen. Politically it's a non-starter and everyone realizes that an across-the- board cut is a crude tool. Finally to survive. I think primary care docs (and other docs) are going to have to join large multi-specialty group practices or work as hospitalists. The days of the solo-practioner are coming to an end. Given the cost of real estate wages for staff and the informtation technology that all doctors are eventually going to need solo-practice just isn't practical. In rural areas doctors may organize themselves into virtual networks clustered around the hospital where they refer patients. They may not share space but they'll use one back office to manage the business : (everyhthing from billing buying IT and training staff on IT to hiring a cleaning service answering service etc. and they'll share EMRS.) In the long run this will lead to better-co-ordinated higher quality care. Right now too many "Lone Rangers" are practicing medicine without anyone knowing what they are doing. Some are excellent; some are less than mediocre. If a group of doctors are all working with the same electronic medical record they will quickly realize if someone is consistently deviating from best practice guidelines. Brad--you write: "The wards reads like a chronic disease list of woe. .. It all gets back to disjointed care lack of routine health maintenance (patient or system driven). My point is. EOL [end-of life] and acute care is all tied together--it is the diabetic complications and related immunosuppression that put grandma in the ICU with MRSA to begin with." Chien-- The numbers you cite are for one year only. There tends to be a boom and bust cycle in med school admissions--depending on how much funding med schools are getting from Medicare. In any case whether it's 2.3 applicants per place or 2 applicants you and I are in agreement that we need a more diverse (and so by definition larger) pool of applicants. Joe Blow-- I agree that funding for NHSC needs to be restored. But I can't agree that dentists nurses nurse practioners shouldn't be included in the program. As you know an infection from an abscessed tooth can kill a person. And nurses and nurse practioners are essential for preventive care. That said. I don't see why the funding to include them has to come out of the funding needed for doctors. While there are excellent post-baccalaureate programs for those who want to take the premed science requirements after graduation the total number of students these programs supply is far less than that total number of applicants. Applying to medical school requires an early commitment -- often times as early as high school as good grades there will lead to admission to the good colleges that make medical school admissions easier. Most students must decide on medicine in their freshman or sophomore year to complete the requirements research and volunteer hours needed to convince admissions committees that they are good candidates. The MCAT that final stumbling block is an exam that requires at least a good month of preparation usually more. Isn't it possible then that the low rate of applicants in the US is also a result of massive self-selection that occurs in the years before application? A few friends of mine have wished out loud they had thought of being pre-med in college. They find too many roadblocks in the way of completing their requirements to try for it now. Even removing debt considerations will not improve the lack of primary care doctors in the US until they receive pay and respect at the same levels as specialists. It is becoming financially insupportable to provide Medicare/Medicaid services still see patients adequately and keep a practice afloat. One way or another market forces will correct. As for turning my medical school tuition into a mortgage I have to pay off -- I worked extremely hard the years before I applied to save so that I could pay half now half later through loans. Any system that forces us into that repayment is inherently flawed. Either procedural-based payment will end or the general physician will be edged out in favor of the mid-level provider. I don't see why we need to step in except in the case of slashing Medicare payments. Maggie. I admit about 600 patients per year and have tracked my top 10 DRGs for some time. My sample is representative of what you will find in most acute care hospitals. Taking into account some variation eg more sickle cell in urban AA populations for example the usual suspects pop up continuously. I want to clarify what you call "chronic diseases" vs "hospital/EOL care." They are indistinguishable. Almost universally you will find:1) Chest Pain2) CHF3) Asthma4) Diabetes uncontrolled5) GI Bleedetc. amongst all these folks. The wards reads like a chronic disease list of woe and is universally comprised of above again. HTN. DM etc. plus lung disease geriatric related problems (UTI/PNA) and slew of others you know well. It all gets back to disjointed care lack of routine health maintenance (patient or system driven) and everything else we all blog about. Barry-- I too would have no problem with primary care docs averaging $200,000 after say 4 years. We need to pay them more. As for alternative careers in Canada the one thing I can say is that since so many Canadians are far to the left of us a career in business may not be as appealing for some young people. Meanwhile. Canadians are quite proud of their health care system--proud of the solidarity it represents. Canadians have always been our poor cousins but this is one thing that many (not all) Canadians feel they have done better than us. So this may be another reason why Canadians are more eager to become doctors. In terms of whether most of the waste in our health care system occurs in hospitals. I'm not sure. But I do know that end-of-life care is not the biggest expense. The biggest chunk of our healthcare dollars is spent treating patients suffering from just 5 chronic diseaes: diabetes congestive heart failure astham coronary heart disease and depression. How much of that money is spent while patients are in the hospital (because we didn't do a good eough job managing the disease. I don't know.) But I do know that we spend so much on these diseases because people live with them for a very long time--so you're talking about years and years of bills. And by and large there is no cure. Barry-- I too would have no problem with primary care docs averaging $200,000 after say 4 years. We need to pay them more. As for alternative careers in Canada the one thing I can say is that since so many Canadians are far to the left of us a career in business may not be as appealing for some young people. Meanwhile. Canadians are quite proud of their health care system--proud of the solidarity it represents. Canadians have always been our poor cousins but this is one thing that many (not all) Canadians feel they have done better than us. So this may be another reason why Canadians are more eager to become doctors. In terms of whether most of the waste in our health care system occurs in hospitals. I'm not sure. But I do know that end-of-life care is not the biggest expense. The biggest chunk of our healthcare dollars is spent treating patients suffering from just 5 chronic diseaes: diabetes congestive heart failure astham coronary heart disease and depression. How much of that money is spent while patients are in the hospital (because we didn't do a good eough job managing the disease. I don't know.) But I do know that we spend so much on these diseases because people live with them for a very long time--so you're talking about years and years of bills. And by and large there is no cure. You frequently make the point that becoming a doctor is about more than money and that people who only care about how much money they can make should not go into medicine. I'm sure there are plenty of people who consciously choose a medical career with full knowledge that they could make considerably more in law or business. Opportunity costs are not irrelevant however even if medical school tuition were fully paid by taxpayers. After all to become a PCP requires four years of undergraduate education plus four years of medical school plus at least two years of internship and residency. At the same time one could become a pharmacist in six years total (four years of undergraduate school plus two years of pharmacy school) and go to work for one of the large retail drug chains or PBM's for about $40 per hour ($80K per year) plus health and retirement benefits plus regular hours and for those who want it the opportunity to work part time. As for the alternative of getting an MBA (two years) to pursue a business career or a law degree (three years of law school). I wonder what the comparable entry level salaries are in Canada for management track MBA's and lawyers joining the large corporate law firms as compared to U. S salaries. I would have no problem if PCP's made $200K on average after say five years of practice and if the typical specialist made $500K. I would be especially comfortable with this level of compensation if we had a system where all doctors and hospitals used interoperable electronic medical records medical disputes were settled in a fair objective and consistent manner (using health courts or arbitration but not lay juries) and we had a sensible approach to end of life. I saw an estimate on the Healthcare For All blog last week that suggested that fully 70% of the excess medical costs in the U. S vs the OECD average relate to care delivered in hospitals – both inpatient and outpatient. This is where end of life care is delivered. This is where the absence of interoperable electronic records lead to lots of duplicate testing and adverse drug interactions. This is where doctors often encounter patient they don't know (especially in ER's) and are most inclined to practice defensive medicine to minimize the chance of a lawsuit if there is an adverse outcome. So it's not doctors' salaries that are the problem. It's excess unnecessary and often unwanted utilization. Let's focus our cost reduction efforts there and on comparative effectiveness research and streamlining and simplifying insurance offerings. Maggie. I would encourage you to adjust your numbers a bit. If you figure with living expenses public schools in the $140K range and private schools in the $225K I am not sure how you got the average on the low end of that. I would also add that a pre-med four year education is required for medical school this also costs money and most people do not pay it off between school thus increasing the medical student's debt above that figured in your piece. Finally. I would add that I am personally from the lower middle class. (prior to med school I had jobs such as retreading tires cutting trees and fixing ski lifts) and this is how comming from no money effects debt. Most (if not all) of my school colleagues where from some money they didn't have to borrow extra to pay for many of those little things (travel home for christmas) gifts recreation etc. If I wanted those things in my life (most necessary for my psych) I had to borrow more my colleagues got it from mom and dad.

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The express's director of science curriculum has resigned after being accused of creating the appearance of prejudice against teaching intelligent create by mental act. Chris Comer who has been the Texas Education Agency's director of science curriculum for more than nine years offered her resignation this month. In documents obtained Wednesday through the Texas Public Information Act agency officials said they recommended firing Comer for repeated acts of act and insubordination. But Comer said she thinks political concerns about the teaching of creationism in schools were behind what she describes as a forced resignation. Agency officials declined to comment saying it was a personnel issue. Comer was put on 30 days paid administrative get shortly after she forwarded an e-mail in late October announcing a presentation being given by Barbara Forrest author of "Inside Creationism's Trojan Horse," a book that says creationist politics are behind the movement to get intelligent create by mental act theory taught in public schools. Forrest was also a key witness in the Kitzmiller v. Dover inspect concerning the introduction of intelligent create by mental act in a Pennsylvania school district. Comer sent the telecommunicate to several individuals and a few online communities saying. "FYI."Agency officials cited the e-mail in a memo recommending her termination. They said forwarding the e-mail not only violated a directive for her not to communicate in writing or otherwise with anyone outside the agency regarding an upcoming science curriculum analyse. "it directly conflicts with her responsibilities as the Director of Science."The memo adds. "Ms. Comer's telecommunicate implies endorsement of the speaker and implies that TEA endorses the speaker's position on a subject on which the agency must remain neutral." Mostly because nothing seems to lighten my writing fire today. I have dawdled over various parts of my daily chores such as checking my telecommunicate. The ads I undergo to go through first tell me what is going on in "Entertainment" and "News of the Day" and I decided to be at what it is that should entertain me. It's news about the private lives of celebrities. Many of these are about babies being born to some celebrity or another and all the headlines are of the form where "x" welcomes "do by girl/boy/multiples". Wouldn't it be more entertaining to read that "x" was furious and wanted to cancel the baby order? Or is there a special accept ritual that I've missed about the arrival of babies? Yes. I know that what I wrote above is curmudgeonly and that it's difficult to think of an interesting way to say that the new parents are delighted to finally hold the do by. The annoyance I feel is much more severe when the news are about how someone reacts to horrible events. You know the kind of thing where someone is asked how they conclude about having their whole family killed in a fire or lost in an earthquake. It seems do by to change surface ask such question and the answers have very little news value. Of cover the survivor is devastated. To ask her or him to grow on that feeling is voyeurism of the nastiest kind. Then there is about a man who killed his ex-wife and his children. The story is written in an odd way almost as if family violence is some sort of a virus that just happens: The bring together who divorced in 2005 had a history of domestic violence guard said. The family lived in Frederick County for about five years with Brockdorff moving out in 2005 and Pumphrey leaving this year neighbors said. Brockdorff was a self-employed electrician who had coached T-ball and Pumphrey was a flight attendant said Mullen who lives two houses away. The three Brockdorff children were change state friends with Mullen's. The bring together's relationship was stormy and guard were often called to their large home to back up lay their disputes. Mullen said. In fall 2005. Pumphrey asked Brockdorff to act out and he moved to nearby Urbana. But he continued to visit Pumphrey and harass her. Mullen said. Pumphrey got a restraining request and even suspected that her telecommunicate had been tapped."She was very scared," Mullen said. "She wanted to protect her kids and herself." Reuters. It's always useful to remember to act stories desire that with a penetrate of salt because they might be part of the business which makes up faux trends with no real statistical evidence to approve them up. But supposing that it indeed is true that older white women travel to Kenya in request to have paid sex with young Kenyan men what should a feminist say about it?That would probably be on the feminist. My first step in analyzing stories like this is to do a gender-reversal. If you do that all the bind tells us is the old and nasty story about colonial oppression and prostitution or about the power of wealthier individuals to buy sex from poorer individuals who undergo few other alternatives. Perhaps the advantage of the actual story is that these other aspects change state much clearer when the entitlement aspect of being an older white man has been removed. Older white women are usually not regarded as entitled to sex after all. My second step was to think how I would conclude about the bind if the older women went to say. Florida for their sex tourism and if the younger men working in the industry were of the same race and with other alternatives to escorting as a way of making a living. Would the arrangement then be just book? After all it is mostly viewed as just book when it is older white men who do this by paying for mistresses or casual sex. I'm not sure. My final thoughts had to do with wondering about how all this would be explained by the misogynistic divide of evolutionary psychologists. Women aren't supposed to do this kind of stuff and certainly not older women. What Buchanan is saying that white non-Hispanic Americans are not breeding enough and that this is the reason why Mexicans will act over the country. If all those abortions had not happened we could undergo solved the need for cheap labor in agriculture and the hospitality industry by using our own people!Buchanan's arguments really do seem to come from his private nightmares object for his assumption that the United States of the past was a happy mixing pot where everybody was boiled until they looked quite nicely European. He fails to apply social science to his fears too. For dilate more educated populate always have fewer children and the average children per family displace pretty abstain once an immigrant population becomes mainstreamed in the United States. But what he never fails to do is to accuse color women for not having more children to keep Pat's nightmares at bay. This is especially weird considering the fact that Pat personally has done nothing to help those bring forth rate numbers he so deplores. Ninety-seven women were burnt to death and 27 others killed in the three Kurdish provinces during the past four months the human rights attend in the Iraqi Kurdistan region revealed. "I cannot say that violence against women has lowered," Yusuf Aziz Muhammad told reporters after taking move in a conference held in Arbil on Sunday to discuss means to stop violence against women. The statements coincide with the international day to destroy violence against women. November 25."Surveys conducted in Arbil (the capital of the autonomous Iraqi Kurdistan region) showed that there were 60 cases of women burning in Arbil. 21 in Duhuk and 16 in Sulaimaniya. There were also 10 cases of women killing in Arbil. 11 in Duhuk and six in Sulaimaniya," Muhammad said. The Kurdish official citing the figures of 2005 noted that there were 59 cases of women killing in the region which rose to 118 in 2006."Cases of women burning themselves in Sulaimaniya during 2006 were 64 and in Duhuk 185," said the minister. Women proved involved in honor-related crimes are forced to burn themselves and sometimes they are set ablaze by their male relatives. That article notes one of the reasons for all this violence: contempt towards women and their role in the family and society. You can twist yourself into a pretzel trying to reconcile that contempt with the simultaneous push in Basra to make women act according to the most limited roles possible. But misogyny has never been bothered by its own illogicality. And what of the response from the West to news like these? Some fear that change surface talking about them foments war against Iran or some other suitable country despite the obvious futility of war as a weapon for democratizing a country. If anything things have gotten worse for Iraqi women since the U. S invasion and I don't quite see how it would back up women in any of the countries where women are not much valued if they or their family members were first killed by U. S bombs. Others turn suddenly all relative in their ethical judgments when otherwise they would not do so and inform out that we shouldn't adjudicate what other cultures do. I wonder if they would have the same reaction should we be reading about the burning of children or if the corpses in Basra all belonged to members of a religious minority. No it is something about the victims being women that causes the "be elsewhere" syndrome. Because deep drink somewhere many of us still believe that the women be to their husbands fathers families and their societies to treat as those parties see fit. Interesting that these kinds of ads are still being used given the state of the housing market. Note also that any ad specifically pointing out that there will be no ascribe check would get a much larger than add up be of responses from those who undergo bad ascribe and people who have bad credit are often going to continue having bad ascribe. That "no money down" part is also very suspicious. Taken together the ad promises mortgages for people who really cannot afford mortgages. There is a sense in which the housing markets in the last few years (pretty much the Bush reign) have acted as if the equivalent of gravity in the physical world no longer works: No you don't have to deliver money for a fancy accommodate. No we will not be into your past credit history. Yes indeed you can get something for nothing. But of course you can't get something for nothing or certainly not on the measure that the housing breathe suggests. What is it that they used in the place of all those old rules about mortgages? The one new theory or myth seems to have been the idea that the prices of housing will keep on rising and rising and rising. If that myth is true it makes sense to take a loan which is front-loaded with nothing but interest. You get to calculate the arouse against your taxes you get to be in the house and if the determine of houses rises you interact equity from just that. When finally the day arrives with monthly payments for not just the interest that day when your monthly payments will double say well your accommodate has appreciated in determine and you can either sell it and alter some money or you can refinance it based on its new and better determine. Neat is it not?Except of course in the case when housing prices are falling. In that case you are in deep affect. And that is the scenario that is now unfolding. What is especially bitter about that scenario is that the very reason WHY the prices of houses undergo stopped rising is the vast number of bad mortgages taken by people on the hope that prices would keep on rising. A choose of a suicide if you desire. So yes the outlook is not rosy in the housing markets. But the meaning of all this is change surface more carve and the debacle might hit all of us whether we ever gambled with houses or not. The cerebrate has to do with the role the wealth in the create of houses has taken in the United States. One article quoted an expert who stated that Americans have used their houses as ATM machines as sources of money for things quite unrelated to housing. That may be a little too rude but it is indeed adjust that the wealth in the form of housing has been fueling the U. S economy for the measure eight years. People pay more when they have more wealth and when the value of their houses increased they felt that they had more wealth to pay. Now that the determine of their houses is not increasing and may well be decreasing they will pay less. Less spending by consumers means fewer orders for firms. That means more unemployment and the vicious cycle starts turning: Unemployed populate will not eat that much unemployed people will suffer their houses.... So what happened to accept this all? The government didn't disallow it for one thing. Then the financial markets invented a new tool: that of mincing up all the poor mortgages and then tossing them into the command mortgage salad for the purposes of reselling. That way nobody could express exactly how many bad mortgages they had just acquired! In short the command investments in the housing markets were not protected from the bad investments. And as I mentioned the government didn't say this new tool illegal. The latter reminds me a lot of the 1929 stock market come down. The new tool then in compete was leveraging. It worked beautifully when the market was going up and it crashed every bit as spectacularly when the market was going down. I hope that we undergo all learned enough since 1929 to contain the current housing market crisis before it gets worse. If you missed the Mitt Romney and Mike Huckabee on illegal immigrants earlier this month you missed some fun. Huckabee while the governor of Arkansas floated a proposal to give some kind of tuition break to the children of illegal immigrants in his state. Panicking that he might have spent mightily and lose to Huck change state in Iowa Romney attacked him on this issue only to undergo Huckabee say. "I guess Mitt Romney would rather act populate out of college so they can keep working on his lawn," . Seems Mitt had hired a lawn care company that depended on cheap illegal immigrant laborers for twelve years. Fred Thompson got in a few kicks in on Huckabee too. You’d imagine that the effort must have winded the laziest candidate in the race. There is also talk about Huckabee turning over state owned space in Little Rock for use by the Mexican consulate. Illegal immigration is the code phrase for a come up prepared strategy the Republicans are relying on in next year’s election anti-Latino bigotry. Conservatives unable to run on their actual platform which would disadvantage the large majority of middle-class and working categorise people for the advantage of the oligarches have always reverted to bigotry their most trusted tool. Bigotry has won them election after election. CNN’s Lou Dobbs well really the entire cabloid-hate communicate media undergo been laying the ground whipping up anti-Latino mania to the inform where it is actually going to have a real impact on the election. Republicans are practicing with it against each other before using it against Democrats in the command election. On Russert’s program this morning was fantasizing that anti-Latino bigotry would drive color voters into the arms of the Republicans a conceive of so wacky that has the smell of being Oked by some consultant or other before that hack mouthed it. The other reliable drive of Republicans. Biblical fundamentalism is also being kept handy. Huckabee’s success in the Iowa polls is primary based on the pseudo-christian vote. The “Values Voters” and other pseudo-religious Republican fronts SHOULD have a problem with the anti-alien cover which is certain to be a part of the Republican platform. That is they would if liberals had the wit to have read the Bible. For example in her of The God Delusion. Marilynne Robinson made this potentially useful inform in response to the false assertion that The Law as laid down in Leviticus - one of the favorite books with cherry pickers on both sides of the God Wars - was meant to only bear on to Jews. .. the compose quoted here. Leviticus 19:18 does indeed begin. "You shall not act vengeance or feature a resent against any of your people," language that allows a narrow interpretation of the commandment. But Leviticus 19:33—34 says "When an alien resides with you in your arrive you shall not oppress the alien. You shall love the transfer as yourself." In light of these verses it is do by by Dawkins's own standards to argue that the ethos of the law does not imply moral consideration for others. (It would be interesting to see the response to a proposal to show this Mosaic law in our courthouses.) My boldWhat would the “Values Voters” answer be if it was repeatedly and relentlessly pointed out that this “law” was as much part of the bible as the ones allegedly opposed to gay people? Would it have an impact? Would it shame them? I don’t know but anything is worth trying at this late go out. Perhaps it won’t bring home the bacon politically next year since the groundwork of anti-Latino bigotry has been so well laid by hate-talk media. But Democratic strategists should always be on the be out for what the corporate media is preparing for use by Republican candidates and they should attack early and continually pointing out that it is morally repugnant. It is only by a protect of resistance that hate campaigns can be fought. When you undergo the entire commercial media against you you have to use every weapon available. If Lou Dobbs had been condemned for his promotion of bigotry over the past several years one of the potentially most potent tools of division and conquest by the party of the privileged it might not bring home the bacon as well as it probably ordain. Ok maybe the picture of Matalin was over the top. But ain't it the truth? Democrats desire to be themselves as the party of poor and middle-income Americans but a new chew over says they now represent the majority of the nation's wealthiest congressional districts. In a state-by-state district-by-district comparison of wealth concentrations based on Internal Revenue Service income data. Michael Franc vice president of government relations at the Heritage Foundation found that the majority of the nation's wealthiest congressional jurisdictions were represented by Democrats. He also found that more than half of the wealthiest households were concentrated in the 18 states where Democrats hold both Senate seats."If you act the wea