The Gap Between "Us" & "Them" Grows

Those of us relegated to an employer-sponsored HMO or other managed care organization already feel like we are in a spiraling vortex where medical care is consuming more and more of our income. My wife is a diabetic and the cost for her monthly medication is almost $500, and that is with the HMO coverage. That doesn't include the amount deducted from her paycheck to cover those expenses.

Recently I wrote about how many in the regular practice of medicine are turning to cosmetic and boutique practices for the purposes of chasing after the big bucks. In that post I bemoned the loss of the concept of "profession." I also decried the fact that more foreign students than ever before are entering our medical schools on scholarship stipends from there native country while our own people are denied access to the training because we don't have an effective financial aid package for our own citizenry. Additionally, I condemned those that entered the field of medicine for the specific purposes of getting rich rather than serving others.

I am formulating a paper on a new model of training doctors and nurses. The first step in this new model is to begin at the lowest level of care. All students seeking nursing or medical credentials will have to have at least 2 years serving in some paraprofessional role, such as nursing aide/assistant, orderly, etc. Then, before moving on to nursing or medical school, they must have at least one year in a more technical service role (i.e. working in radiology, labs, phlebotomy, etc.). Then, after completing such service, and maintaining adequate grades in college courses, they can be admitted to either a nursing program or a pre-med program.

Pre-med programs must include some training in the field of nursing as well as the hard sciences, psychology and clinical education. Prior to entering graduate work, there must be at least one year actual work experience in a medical setting (for which college credit is associated). All short curriculum programs (i.e. diploma programs) in nursing are eliminated because they provide the fundamentals, but do not produce the quality of nurses we need in the healthcare setting. Associate degree nursing programs will have less "liberal education" requirements and more focused courses, which would greatly expand what is now required.

Medical school admission would no longer be decided upon the MCATs alone (which is the case with far too many medical schools). Instead, the MCAT scores would be a 15% component of the admission decision, while grades and performance in courses specifically focused on hard sciences, nursing and providing some basis for caring for others (rather than overall GPA) will be a 50% component. Ten percent of the decision will be based overall GPA and academic performance and the last 25% will be based on evaluations made by those that actually supervised the applicant in medical settings, including an assessment as to how motivated the applicant is on helping others. A similar approach would be used to assess applicants for graduate degrees in Nursing and Nurse Practitioner programs, as well a Physician Assistants. The number of PA and NP programs would be increased.

Additionally, unless the student paid for college and graduate school out of their own pockets, each graduate of an associate degree program would be required to work two years within a national public health program that provided services to everyone in the US (more on that later). Bachelor degree graduates would be required to work three years. During the time they serve in this national public health service, their salaries would be entry-level, but their debt for school loans would be reduced. If they complete the service, their debt would be erased upon completion of the program. Graduate level graduates would be required to work 4-7 years (depending upon the program) in addition to the years of service required for lower level degree achievements. While the compensation for this period of work would be somewhat reduced from what a civilian employer might pay, the participant would be eligible for student debt payoff, additional training sponsored by all government healthcare resources (i.e. NIH, military courses, FDA, USDA, USPHS, etc.). Additional training in disaster management, terrorism response, emergency management and public health outreach, as well as work in these areas, would be provided and would be mandatory.

While I haven't fleshed these ideas out completely, the idea is one of service to the community, state and nation in return for benefits. In the process our public health response would return to the forefront of our society, we could implement a national healthcare program at reduced costs, and we could return our nation to the level of technical and service achievement we once held in high regard. Part of the duties assigned to students during their public health service would include health inspections for buildings, restaurants, food processing, etc.

Of course, these ideas are based on my experience as a US Navy Hospital Corpsman, A corpsman can do nursing care, emergency care, health assessments, preliminary diagnostics, facility inspection, minor surgery, laboratory work, food service inspections, and more. I received training in all aspects of medical and nursing care. In my days on active duty I performed over 400 psychiatric assessments, administered psychodiagnostic assessments and tests, over 300 minor surgery cases, managed an ER shift and ambulance crew, as well as recived advanced training in communicable diseases, blood component therapy, IV administration, physical therapy, occupational therapy, eye care and diagnostics, dental care, emergency medical techniques, orthopedic care, neurosurgical care, and so much more.

But right now the relaity is that we are losing doctors to the lure of money in boutique practice (and we even have tv shows about it) and no longer have an adequate medical coverage for anyone, even those that can afford to pay out of pocket.

When the Joneses Can’t Keep Up

In article in yesterday’s Times about obstetricians who prefer working in Botox boutiques is a reminder that the growing gap between the rich and superrich has an impact on those of us who are neither. The article, by Natasha Singer, reported that family practitioners and emergency room physicians have also jumped over into the cosmetic treatment business because the money is so much better.

As The Times has noted in a series of recent articles, the very richest earners are increasing their earnings at twice the rate of their onetime peers, and the average-rich are taking resentful note. Investment bankers are jealous of hedge-fund wunderkinds and, from the sound of it, almost every last person in Silicon Valley is envious of the founders of YouTube (with the likely exception of the Google billionaires who bought their company).

It’s hard for people flying in coach to have much patience with those in first class bemoaning their lack of a personal jet. Neither policymakers nor society at large need sympathize with the longing of millionaires to become billionaires. But we do need to worry about the effects on society as a whole when members of the educated elite think they are grossly underpaid. The more they feel as if they are losing ground against their peers, the more likely they are to ditch professions in which the pay is only good — like delivering babies — in favor of less useful careers in which the compensation is off the charts — like eliminating lines from wealthy people’s foreheads.

America has long had a problem attracting enough well-trained people to important but not particularly well-compensated positions, like public defender, social worker or teacher. But an era in which a cancer researcher moves over into health-care management consulting because the pay is better — as Louis Uchitelle reported in The Times this week — is something else entirely.

Part of the explanation is undoubtedly a tax code that has sent the incomes of the wealthiest sliver of the nation into hyperdrive. Another might be the spike in education costs, which send many new doctors, lawyers and scientists out into the world armed with a diploma and a six-figure debt. But the bottom line seems to be that in 21st-century America, more people can’t feel successful unless they’re making a killing.