how important is salary?

Good, I think we are starting to find some common middle ground here.

We all have to understand your organizational structure before knowing how STARK applies to you in particular. So let's move on from that, hopefully with the common ground that it is a good thing that physicians are no longer able (theoretically) to increase their incomes by modifying their referral patterns. I think we can all agree that what is truly sad here is that this was required in the first place! But as you say, humans respond to incentives. It is unfortunate that the AMA, among others, tried to perpetuate the idea of the infallible physician for so long.

On the topic of Medicare expenditures decreasing...this is such a monster of an issue, with so many factors to consider it isn't funny. By the way, I believe teachers also often face decreases in their earning power (I believe 40 of the 50 states last year didn't keep up with inflation). None of us are smart enough to completely understand Medicare (if that were even possible). But many of its modifications over the years have been targeted at physicians who (consciously or not) game the system in their favor. They had to create DRGs and Fraud and Abuse programs to name a couple. Again, hopefully we can agree that it is sad that as "professional" "scientists", we created a "product" that simply hasn't fared that well in retrospect. Albeit there are some great examples of healthcare improving the lives of its patients, there are just as many examples of it failing to do what it intended. Much has been written about variations in practice patterns based on geography and the density of physician services in a given area. Yet more and more justification for society to view physicians not as god-like infallible "professionals", but, just as EarthDawg indicated, humans responding to incentives. I believe that in the big picture of the history of medicare, it makes sense that they are reducing the money going to physicians simply because they are realizing that they have been overcompensated in the past (or at least took advantage of the system).

Now, the challenge, as you suggested and I agree, is to find the correct levels, of both physician reimbursement and the number of physicians. Many well-educated, decent individuals believe there is no shortage whatsoever of any kind of physicians. Perhaps you don't need an OB-GYN doctor within 3 hours? You might think that statement is ridiculous, but just bear with me in my hypothetical scenario. Consider, society is in many ways making that decision by allowing it to happen. Midwives can fill the gap and manage the overwhelming majority of uncomplicated pregnancies for a much lower cost. Perhaps rather than interpreting this with emotional outrage, we can see that society is telling us something. Namely, I interpret this that society is saying it is better off to pay less and to have the overwhelming majority of pregnancies handled just fine, while making those unfortunate ones who need an OB doctor travel 3 hours. At some point in the continuum, we (society) have to make a choice, we must weigh the costs and benefits.

So why shouldn't it be like this. PAs and NPs? If they can provide services with equivalent outcomes to that of an FP trained doc, then who cares about their education? Isn't it BETTER OFF FOR THE PATIENTS, because now more money can be spent elsewhere, whether on a new hip for grandpa, better education for little susie, or a 3rd SUV for the family?

We are brushing on what I consider to be some very complex issues. If we truly hope to learn anything and educate others in this forum, then we need to reduce the emotion in our posts and try to boil the arguments down to what we are really saying (rather than tackling multiple topics in one post and claiming patient care as the ends that any means must achieve). So I am trying that now (with the caveat that I am open to modifications of my arguments for the sake of my own education).

I certainly agree that financial concerns are worth considering, I'm pretty sure that is a given. However, I also know relatively where I stand on the supply and demand curve for orthopods. I know that we are far, far from a level where I would pack my bags for D.C., but that point will come at different times for us all. If you feel the value of your services is greater than what you are being compensated, then you can:

A. Reconsider your analysis by realizing the positive externalities of being an orthopaedist are just as important, if not more so, than the wages you earn.
B. Lobby for higher wages (or try to push to unionize orthopods so that we can collectively demand higher wages)
C. Take your valuable self elsewhere (other country?, other industry?)

If you consider yourself more valuable than the "average" orthopaedist does, then you will be frustrated by a lack of effort by your colleagues on this topic. Not until the "average" orthopod is undervalued will we, as a whole, create and see changes in our "favor". If no one can hire a traumatologist at your place (or say, the entire country), then supply will rise, prices will fall, and dynamic equilibrium will be achieved.

OK, I am done for today. This is kinda fun, but for the amount of energy we are putting into some of our posts, we should try to at least get something out and recognize when we are wasting energy in some of our arguments.

I am also stuck needing to upgrade from my Super Nintendo. Any suggestions? I hear those last few months of 4th year are a great time to get your gaming back on.

i am not sure why you have problems recruiting a trama doc ... we are fortunate ... we have 7 in our group ...

you must have a freakin huge group then, since only about 25-35 people in the whole country do trauma fellowships each year in the US. Compare that to deluge of spine and sports people each year and it is easy to see why some places just cant find a trauma guy. Peds guys are just or more uncommon these days too...

our group isn't that large but we do have an excellent trauma service ... known by some as the "Detroit Mafia" ... although we are not in detroit ...

ahhh .... i got a slow scoli clinic ... it is the slow season ...

md007,

You are making assumptions about me which simply have no merit based on my previous posts.

1. I do NOT consider myself underpaid. I am quite happy with both the financial and non-financial benefits of my practice, so I don't need to "reconsider", "lobby", or "move", but I will keep your handy advice in mind. I AM concerned about declining reimbursement and empathise with our pediatric and family practice colleagues who I DO feel are underpaid considering the amount of training they required compared to other fields. This whole thread was kicked off by asking whether people would still consider ortho if it paid $125K per year. At last count roughly 50% said "probably not" or "nope" so I am certainly not in a miniscule minority when it comes to this issue.

2. I, like yourself, am a huge proponent of the free market system. I think anyone in our society should be allowed to earn EXACTLY what the free market will bear, including physicians. I don't fault professional athletes, lawyers, business people, etc for earning fantastic salaries. I simply think physicians should be allowed to operate under the same rules. Physician reimbursement is but a FRACTION of the total cost of health care in this country. If a physician or group refuse inadequate insurance plans, I don't think they should be condemned by their colleagues as uncompassionate or only money driven. Your cute little example about the family having more money for a 3rd SUV or grandpa's new hip ignores the following fact: Physician reimbursement has fallen in the face of RISING, not FALLING health insurance premiums and INCREASING insurance company profits. I don't think that "physician greed" and "taking advantage of the system" can completely or even closely account for the rising cost of healthcare in our country. It is naive to assume so.

3. To put the STARK issue to rest. I am not PERSONALLY involved with any STARK issues. Our community needs at least two trauma trained orthopedists. The hospital has been trying for years to recruit. There are multiple reasons behind their failure - relatively poor state, undesireable location for many, relatively few natives pursue medical careers, etc. The hospital has been offering candidates a salary that, as I understand it, can't exceed a certain percentile of all traumatologists or they risk violating STARK laws. They would probably offer a million bucks a year, but can't without raising eyebrows. By md007's logic, the law of supply and demand would dictate a traumatologist could earn a million bucks a year in this particular market and should be allowed. But because that traumatologist happens to be a physician, he or she shouldn't be allowed to make that type of money. As a result, we have a shortage - and rest assured, it isn't just my perception. I am all for letting society "make the decision" on what physicians are worth, as long as it works both ways and the market is allowed "demand" when the "supply" is short. I am of the opinion it is conspiring insurance companies and beauracrats in charge of puble payors that unfairly tip the balance of power.

4. Enjoy 4th year of med school. It is now obvious where you are getting your idealistic view of the medical system - you haven't worked in it yet. You may want to resist being too critical of those who discuss financial issues surrounding medicine until you have been to the front line. This is just a stab in the dark, but you just may have a change of opinion in 5-6 years when you are practicing yourself.

5. I am really not getting emotional. In reality I am bored because the weather sucks and half of my patients have not shown up for clinic. You can presume about me what you wish - my motivations, my and my colleagues little schemes to bilk money from medicaid, whatever. I am simply defending those who consider financial issues in medicine, because when it comes down to it, EVERY physician has a price. While you may consider it shallow and uncaring to refuse to practice orthopedics for $200k per year, I bet that you yourself would not pursue it if you made $12k per year. How could that not also be considered shallow, greedy, and uncaring? Although the threshold may be different, rest assured, EVERYBODY has a price, even yourself.

EarthDawg - Thank you for your wisdom. As a lowly 4th year medical student, I rest humbled and dominated by your expertise. I am concerned, however, that you think I am making assumptions about you (your words), yet you specifically make assumptions about me because I'm an ms4. Did you even consider that I might be older and more experienced in healthcare management and economics than you? Should that even mean anything anyways? (I would argue that it should not, as we can debate about principles nonetheless, but I guess you feel different)

When I write about past and current problems in our healthcare system, I am not pointing out anyone. I am sorry that you feel this all comes down as an attack on you, but it is an attack on the entire system and process, of which I too am a part. Individual physicians have certainly made choices that were more in line with their financial interest than with patient welfare, and it would be nice to think that those are the evil ones that we need to get rid of. However, and despite my wishful thinking sometimes, this is virtually impossible, and often times these actions are done by honest, hard-working, patient loving individuals who are placed in a bad situation by the system itself.

You also assume that I am a "huge proponent of free market system". This is another monster about which we should be careful in making these gross overgeneralizations. I do have tendencies toward the chicago way of economic thinking, but have never seen or heard of a free market healthcare system in the united states that holds up to any ethical line of reasoning with justice or equality as a primary value.

And you're right, maybe I will change my mind in 5-6 years, after I go through residency training that has a tendency to rob people of much of their compassion. But do we not agree that the more diverse opinions the better? Isn't this the only way to ensure long-term integrity in our society?

Maybe you will also change your mind.

let's get back to the main topic of this discussion ...

financial issues, those who are not currently in a field, where orthopaedics is a consideration .... if you have gone into medicine understanding the state of medical affairs now, you know that the physicians make less or the same as they did 10 years ago ... you understand you will probably not make a million dollars ... so why chose a specialty based on that ....

you know .. i will put up another poll .... and ask why have people chosen orthopaedics as a specialty ... maybe we will be able to answer some of those questions[/quote]