Sunday, August 24, 2008

Fifteen days of blogging for health care reform: Burden of debt

Guest post by Skylanda.

Not long ago, I was cruising along the highway at about 75 miles an hour (hey, it’s a rural state, that’s not even speeding here). I was headed north to sign some papers; after innumerable years on a student budget (four undergraduate years, a couple more to the premed classes I hadn’t taken the first time around, four years of medical school, and a year to complete my masters in public health), I finally had a solid resident income. I somehow managed to wangle a mortgage out of the messiest era in history to lock down a line of credit, and I was buying me a house.

The sign at the roadside was for a casino. This is Indian country, brightly lit casinos cling to the highways and byways like hummingbirds on honeysuckle. The billboard glittered and flashed and promised - wow! - a half million dollar jackpot. Top prize! Some lucky soul will take it home!

A pit opened in my stomach and I almost turned around and called the whole thing off. Half a million dollars, I realized…if I signed those papers, half a million dollars would no longer pay off - nay, not even come close to paying off - the total dollar amount I owed to the world at large for the enormous debts I had accrued over the last five years.

I kept driving. I signed those papers. I am now thirty-three years old and the proud owner of two-thirds of a million dollars of accumulated debt. Far, far less than half of which is tied up in that real estate deal.

Four years of medical school, one year of graduate school to obtain a masters in public health. Fifty-something thousand a year, add on five years’ worth of accumulated interest (capitalized twice when I lost eligibility for deferral due to quirks of the federal loan program), and you have my total school debt: three hundred thousand dollars. When those loans skid into repayment two years from now, they will cost me about three thousand dollars a month to service - that’s thirty-six thousand dollars a year in loan payments alone, more than my entire take-home pay as a resident last year.

In some ways, I struggled. The vast bulk of those loans contributed directly to tuition; the living expenses portion of my student loans put me within about 150% of the poverty level after you subtracted unavoidable school expenses from the checks cut to us every three months. By then my parents had their hands full with other financial obligations and could not by any means put me through medical school; nor did I have a partner to share expenses with. My home state boasts all notoriously competitive medical schools, and though I was accepted to several schools throughout the country, I would have paid private school or out-of-state tuition at all of them - and so I just chose the one that best suited my needs.

In other ways, I was lucky. I have no debt from my undergraduate years, thanks to parents who were both generous and able to support me through those years. My medical education coincided with historic interest rate lows, and I have the majority of those debts locked in at rates that would make you drool (and here’s my public service announcement for the day: if you have unconsolidated federal student loans out there, talk to the Direct Loan people now). I had a lucrative contract job leftover from my former career that I could squeeze into vacations and off rotations, and if I was willing to work eighty-hour weeks while my classmates were playing on their off time, I could pull down a reasonable income. And that I did, pulling in roughly $40,000 in real income over five years; I figure it like this: I came out of medical school no savings at all and living frugally most of that time…if I had not worked that contract job, I would be $40,000 in the hole on credit card debt just to stay even.

Three hundred grand debt from student loans alone, thirty five years old by the time I start making a full physician’s salary, no retirement in the bank, a couple of toes in the dicey-est investment in the market today (real estate, that is), and that’s what I’ve got. So if you ask me if doctors - especially primary care doctors - make too much money, I might just have to say no.

Debt is only one reason that doctors expect to be compensated a certain way. Another is the soul-sucking vortex of the residency years. Until you’ve lived a medical or surgical internship, you can’t really compare it; it destroys marriages, sparks mental illnesses, invokes ulcers and bouts of depression and vague hints of personality pathologies in even the most stable and competent people. In 2003, residents nationwide were put under work hours limitations for the first time - eighty hours a week no more than thirty hours at a time, can you imagine the luxury (luxury, I say, because prior to that, hours worked by residents were totally unlimited). During my intern year, I ran roughshod over these hard-and-fast “rules” with alarming regularity; my department made it clear that so long as they did not get caught at it, they did not care. The week I broke a hundred hours I calculated my hourly take-home pay for those seven days: $6.68. I could probably double that wage at Starbucks.

And then there is the fatigue, that bone-aching tired than never leaves you, so tired you can’t even conjure up a yawn anymore, so tired that sleep no longer helps. Because there is no universally validated scale to measure fatigue, imaginative means have been invented to measure this otherwise very subjective parameter; one study standardized fatigue on a scale of blood alcohol level equivalents, and compared residents after a thirty-hour call shift unfavorably to a blood alcohol beyond the legal limit of .08%. During my intern year, I woke up behind the wheel of my car at stoplights, wrote and submitted admission notes so asleep I didn‘t recognize them the next morning because my eyes were closed and flitting around the inside of my eyelids in the throes of REM sleep as I was typing them, lit my kitchen ablaze after a scheduling glitch forced me to fire off two thirty hour shifts with only a seven-hour sleep between them, stopped eating because I fared better through on-call nights if I didn‘t hit that hard downswing in energy after dinner. I lost twenty-five pounds in three months; people I didn’t know asked me in the grocery store if I was alright. Fatigue makes you learn what it means to hate irrationally, it’s the closest most people in modern industrialized nations come to engaging their most primal needs; you have no idea how much you would give for something as simple as sleep until you have done several months back-to-back staying up all night every fourth night.

So let’s see a show of hands of people who would, under any circumstance, choose to let a doctor (in training, no less) who is in their twenty-eighth hour without sleep for the second time that week take care of your urgent problem - your heart attack, your critically low blood sugar, your c-section. Anybody…anybody?

The work-hours regulations were born in New York state after a particularly notorious case of harm from an overtired, overworked resident; the dead victim was no different than a hundred other victims of exhausted residents, except that Libby Zion was the daughter of a local lawyer and journalist, who had the voice and the wherewithal and the bewilderment to ask in a very public voice why we needed impaired doctors taking care of critical patients. Nearly two decades years passed before New York’s pioneering (and meager) regulations were extended into the national work hours limitations, and even these are under continual fire (one notorious controversy surrounds conflicting data on medical floors - where resident hour limitations have consistently shown improved patient safety - and surgical floors, where the data has not shown improvement; though much hoo-hawing has been made over this paradoxical discovery, anyone who spends time with residents knows that the policy of yanking accreditation for programs in violation of the work-hours rules means that surgical residents are under great pressure to simply lie about their hours…and that is all I will say in a public forum on that matter).

I rotated through a hospital in Britain during my fourth year of medical school. One afternoon I asked the wild-eyed, bushy-haired Irish attending physician if I might show up early the following morning to see my patients before we started rounds as a group at the ripe hour of nine am and thus be better prepared to present their problems. He fixed a jaundiced eye on me and said, only half in jest, “You Americans, we know about your habits…you all think something very important happens before the sun rises, that if you’re not here every moment of the day you’ll miss out, you want to start the morning earlier and earlier. Well, we don’t want your over-eager, overachieving ways here, you will keep that to yourself thank you very much…you will arrive at nine am and not a minute earlier!” I heeded his stern warning and dutifully slept in til 8 am the following day. In Britain, you see, trainee doctors are limited to more or less sixty hours per week. Somehow, they turn out world-class physicians, not unlike American physicians. Somehow, they do it without the soul-sucking demand of the eighty-plus hour work week.

One way they do it is to start medical training earlier, and stretch it out longer. British medical student go to high school one year longer than Americans, but start medical school right after that. Medical school is also one year longer, and then begins a rather extended period of post-graduate training. It is hard to compare the two system because chronologically they are so different, but one thing is clear: they both turn out good doctors, and one does it without asking its acolytes to bow to the god of the 80-hour work week. (As a side note, there is some serious grumbling about reform of the content of the US medical curriculum; the first licensing exam is heavily biased toward non-clinical material, a raft of detailed information that students are forced to memorize then promptly forget after they past the test, which forces medical schools to spin their wheels the first two years on topics of limited use to a practicing doctor. It is questionable whether - in a world where clinical knowledge is expanding exponentially - we still need such an emphasis on a classical education where the detail of theory is emphasized to the exclusion of practical clinical material. This is unlikely to change any time soon, but the time spent rememorizing and forgetting the Krebs cycle certainly contributes to the frenetic pace of learning required later on if one is to master the practice of medicine in the limited time allowed by an American medical education.)

You cannot pay people enough to make up for what they endure during the typical residency in America - especially surgeons, who endure five or more years of it, and who are largely at the mercy of unlimited work hours despite clumsy efforts to the contrary. Cash is all we offer doctors in return for those years of their lives (other old-fashioned notions like renown and universal respect are largely phenomena of the past), and that cash has to compensate not only for the sucking vortex of the residency years, but also for the enormous debt and interest that medical students accrue.

As such, expected payment over a lifetime necessarily has a profound impact on how medical students choose their future careers. Many choose by following their passion alone, but many have multiple areas of interest and make the final decision on which promises a quicker loan payoff, a better guarantee of a reasonable age of retirement, a promise that their investment in their education would not have been better spent on a computer sciences BS capped off by a two-year MBA (which, frankly, is what I would tell any 18 year-old to do if they professed an interest in going into medicine purely for the money - there are quicker, easier, and far less painful ways of making a buck, let me tell you).

Why is this of interest to you? Because there is profound and growing crisis in the staffing of primary care services in this country, and because the increased reliance on specialist services is one of the driving factors behind increasing medical costs. In some ways, this is a region-specific phenomenon; in my adopted home state of New Mexico, for example, every specialty under the sun is in grave demand, from family medicine to dermatology, and whole agencies have been set up to recruit all sorts of doctors to all sorts of regions. But in many areas, recruitment into primary care is suffering from the growing emphasis on specialist care, care that costs more to provide without clear evidence of improved outcomes per dollar spent.

So how can one balance my two assertions above - that we cannot pay doctors (especially in certain specialties) enough for the tortuous training they endure and the debt they acquire, and that we cannot afford to continue to pay certain specialties as much as we are paying them now? First, we can reform the medical education system to treat trainees in manner more akin to the way patients expect to be treated: humanely, with respect to human limitations, and with the idea that residents are not an limitless pool of cheap labor that hospitals might otherwise have to pay a real attending physician a real salary for. And in return we can ask that once they graduate, they not expect to command limitless sums of cash for their troubles. These reforms might have to include starting medical school earlier, with less undergraduate training (a tactic already in place at a handful of US institutions that combine undergraduate and medical school into a single six-year program); reorienting the emphasis away from basic sciences and toward more clinically useful practices earlier on to lighten the load later; and offering longer residencies in exchange for reduced hours. These reforms might also have to include giving residents a voice at the planning table; unionization of trainees at my particular residency proved to be a rapid and potent means of improving working conditions and benefits, and the improvement in those conditions visibly cascades back down into patient care.

Second, keep a lid on medical education costs. The prohibitive cost of medical school not only has a profound effect on specialty choice at the end of school, it also has a prohibitive effect on the diversity of students who enter medical school. It takes a solidly middle class outlook to believe the fanciful notion that a $60k per year outlay will ever pay itself off, and for potential students who do not arrive with significant family support, living on student loans well into one‘s twenties (or even thirties) is still a struggle. Any hope of maintaining diversity in the medical profession will rely heavily on keeping the doors open to medical education, and that means keeping some kind of cap on the ever-expanding cost of attending school. We subsidize every other form of education in this country, and medical education should continue to be no exception.

Third, we can restructure reimbursement away from the current emphasis on high pay for procedures and low pay for the kind of work that primary care doctors do - medication management, counseling, dealing with the problems of life. Small procedures that take ten minutes (and no greater skill or capital input) often reimburse at ridiculously higher rates than an hour spent attempting to get a diabetic’s blood sugar under control - though the latter may have a far greater impact on the patient’s morbidity and mortality over the duration - for no greater reason than mere custom. Careers should pay in proportion to the training they require and the benefits they provide, not arbitrary notions of the importance of procedures over non-procedural services. (Britain - one of the most notoriously socialist of the European medical systems, where doctors are actually employees of the state - recently used a classical market-based approach to try to solve their crisis in primary care: faced with a dearth of GPs and a rapidly aging population, they simply offered to pay them enough that the profession all of sudden became lucrative again.)

As for me, I chose family medicine over my other more lucrative areas of interest because of the philosophy of service and the wide-ranging skill it would provide me. Except for the days when I sit down to calculate how many hundreds of dollars of interest are accruing on my loans each month, I don’t regret it. I know a few folks who have no student loans; they are the ones who will go wherever they want to work, who will go abroad and blow a few months volunteering with Doctors Without Borders after residency ends, who have the choice to work at the lower end of the pay scale for community clinics instead of counting every penny toward that debt pay-down, who can feel righteous about their choice to work for lower pay because they don’t need to make those $3k a month loan payments. I’m not one of those people; my every choice for the next ten years will be driven, necessarily, by money. Ironically, I went into primary care despite the money, and because of that, money will drive my every decision until that last penny of debt is paid off.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.