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Tuesday, July 31, 2012

Setting the Record Straight on Doctor Pay

The following is a response by Joseph Valenti, MD, to commentary published Friday in the Dallas Morning News by Eli Lehrer, president of R Street. In the article, Mr. Lehrer claims U.S. physicians and health care workers make too much money and are responsible for the high cost of medical care in America.


Dear Sir:

I am a physician in Denton, Texas. This morning, I sat and read your article in The Dallas Morning News titled “Your Doctor’s Big Fat Paycheck.” Frankly, I am in awe of the breadth of your ignorance.

Fact: Of the health care dollars spent in this country, physician salaries make up about 8.5 percent. That is one of the lowest percentages in the industrialized world. Germany, by contrast, is at 15 percent.

[RELATED: Dallas County Medical Society President Sets The Record Straight, Too]

Fact: The graduate level course of study for nurse practitioners (NPs) and nurses is not even close to that of physicians — we have a little something called residency. Perhaps you’ve heard of it. When I did mine in OB-Gyn from 1994 to1998, it was 90-100 hours a week for four years with a take home pay of $20,000. I was raising a family on that, as my wife had to stay home to take care of premature twins. NPs and nurses do none of that.

Fact: Private insurers are already too strong. “Weak bargaining position”? If you don’t like the contract they offer, they tell you to take a hike. Doctors are the ones with no bargaining position. I haven’t had an increase from United Healthcare for 54 months. Meanwhile, it paid its shareholders an 11-percent dividend last year. And regarding your comment about how individual plans rarely cover one-half an area — do your homework! States like Alabama have Blue Cross and Blue Shield covering 90 percent of insured lives! In any other industry, this would constitute a monopoly.

Fact: Medicare increases have been had by every segment of the health care industry except doctors. (See the charts.)

Fact: Pilots may make less than doctors. They also belong to unions and walk out when they don’t get what they want. Doctors never walk out, and the pro bono and free care we hand out can’t even be deducted from our federal taxes as charity. Then try breaking it down per hour. Pilots fly about 60 hours/month. Doctors work in the office and hospital about 60 hours/week. And that doesn’t take into account nights and weekends on call. Don’t get me wrong — pilots are vital and do a great job. But on a per-hour basis, they are clearly ahead. By the way, I don't know a single primary care doctor who makes $200,000 a year. Most of the ones I know are barely getting by, and many are closing their practices or selling them to hospitals.

A huge doctor shortage is looming. We cannot and will not attract our best and brightest students to medicine unless their pay is commensurate with the level and intensity of work and commitment needed to fund a modern medical education. The student loan burden alone, which is now often exceeding $200,000, keeps many away.

The huge amount we spend in this country for health care has far less to do with medical professionals’ salaries than it does with the cost of almost everything else. Case in point: The same Mirena IUD, from the same single factory that Bayer uses in Finland, costs $700 in the United States but costs $250 in Canada. Really? That same case can be made for tens of thousands of drugs and medical products here.

Medicine is one of the only businesses I know of where the increasing cost of doing business can’t be passed on to the customer. Every year, the cost of running my office and paying my employees goes up, while insurance payments stay the same or go down. I am left to eat the difference. My salary the last three years is less than I made 14 years ago when I started in private practice. Hardly a source of bankrupting the health care system.

Shakespeare said that the eye sees what the mind knows. With that in mind, ask yourself if you would feel comfortable entrusting your care or that of your family to someone with less training, less knowledge, and less expertise. Would you? I think not. Now ask yourself how happy one of us would be treating someone like you, who wrote an article that is so misleading about us and who we really are and what we really have done to become really good at taking care of patients. Surprise. We would love to take of you. Why? Because that is what we took a vow to do, a vow that doesn’t allow us the luxury of being judgmental. So the next time you are lying in bed needing emergency surgery, remember this — we will be there. Pay or no pay. Assign a value to that ideal, and then consider whether or not we are “overpaid.”

Sincerely, 
Joseph S. Valenti, MD, FACOG

260 comments :

  1. Michael DarrouzetJuly 31, 2012 at 6:05 PM

    Thank you, Dr. Valenti, for writing this very strong rebuttal!

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    1. I totally agree with Dr. Valenti. I spend a lot of my time as an office manager and surgery scheduler explaining insurance and the allowables to our patients. Our allowables for most of the surgeries are far less than what we earned 20 years ago. Back then we didn't need computers, we had a smaller staff, and our expenses were more reasonable. Everyone needs to become more informed.

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    2. Thank you very much for this response. We all very much appreciated it, on behalf of myself (a PCP), the nurses and NPs that help me run this practice, and all the techs in my office!

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    3. I am a nurse and have to admit I was slightly miffed at the nursing comment, but this article is completey accurate! Surgeons and other specialties make a decent living, but other than that it is much less. The amount of schooling and training is intense. It maks me so angry to know that business people make so much more..for what? Do they save people's lives? After reading the comments posted regarding nurses, yes we deserve more money and we serve a vital role in pt care, but so do doctors. I think it's more important to respect each other and our roles instead of having a pissing match!

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  2. Thank God a Physician is speaking out, at last. There is no respect, in this country, for doctors and that alone incences me. My husband is an ER doc. As an independent contractor he does not get assigned time for vacations or sick time/or pay. In fact he is facing prostate cancer surgery and will need to be off work for about a month(of course without pay) Every day he treats patients who do not, or cannot pay for their treatment. Lehrer is a complete and misinformed idiot. I am so tired of the mind set of these moronic people, who think they have all of the answers to this abysmal economy. They need to back off Physicians because, as you said, there are going to be less applications, in the future, of top qualifying students into med schools, and more physicians takng early retirement, particularly once Obamacare really takes force in 2014.

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    1. See, I here all the time that doctors tout for obamacare and how great it would be to make sure everyone is covered with healthcare insurance...but there will be higher costs for people that actually have to pay for their care and doctors will for sure get less pay, but yet the (so called low income people don't pay a darn dime for care....how fair is that...and that will also mean more work on the doctors.....So why so may docs want obamacare in the first place????

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    2. Because, more than anyone I think most doctors believe that everyone should be entitled to healthcare.

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    3. No. No one is entitled to the labor of another. Health care is not a "right" like freedom of speech or speedy trial. It is an industry. What is your job? Are people entitled to get what you make for free? Imagine if they thought they were. How much would they value you and your service? When I give free care to my patients, I expect a thank you.

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    4. Healthcare shouldn't be "an industry". That's the first problem regarding healthcare in this country.

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    5. As the wife of a physician, NO ONE is entitled to healthcare. Like the rest of us, work & EARN it. The doctors my husband works with (hundreds) don't want Obamacare because of the complete HAVOC it will wreak on our healthcare systems nation-wide. When people work for something, they appreciate it more & are less likely to abuse the opportunity given them.

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    6. Replying to Anne:
      As an actual physician, I sincerely hope that your husband's attitude toward his profession and his patient's is more enlightened than yours. The idea that a doctor would think that a sick person does not deserve to be treated because they can't afford healthcare goes against the very oath we take as physicians.

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    7. It shouldn't also be a right. In my country everyone is entitled to health care - as a result you wait for endoscopic USG about a year, for MRI too, to get to a specialist - more than a half year, and so on. And in the meantime the MRI machine may broke down 'cause it's old, and hospitals are in a huge debt. And most people who can afford it go privately.

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    8. I am a teacher and we provide a "free education" to many.

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    9. Dear Teacher- you get a salary if you teach. period. we depend on insurance companies to pay us.

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    10. For those who don't believe Healthcare is a god-given right:
      Imagine yourself in the front of the hospital, when an impoverished 40 year old man, with his family, tries to get care for an obvious heart attack... Now imagine you're the one who has to tell this man, his wife, and his 2 children, "Sorry. You can't afford to pay for your care, so we can't let you in."
      Without healthcare for all, that is what you are facing....

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    11. One person's labor cannot be another person's right.

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    12. Sure it could... in 1860. Or is the U.S.S.R.

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    13. it's funny that if your car breaks down, people grudgingly pay the mechanic the costs to fix whatever's broken...

      but when it comes to their own body, everyone feels entitled to free care to fix the issue...

      nothing is free in the world, not even health care. someone has to cover the costs of medicine. maybe the more important issue here is the outrageous costs of care (at which point it's the pharmaceutical companies fault, not the doctors who have a razor thin profit margin to begin with.) to the person who believes healthcare shouldn't "be an industry", don't be naive. all the physicians pour many more hours than you can ever imagine, sweat and blood into their profession. it IS an industry because you have people trying to make a living off of their craft, and there is no way it can be sustainable (keeping physicians in medicine, attracting future physicians into medicine) in this business model. it shouldn't even be a question of whether or not they should be compensated fairly. no one is expecting a fortune, but when it begins to appear that staying in medicine as a practicing physician will in the long run, be more trouble than it's worth, you have a problem.

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    14. "One person's labor cannot be another person's right." "As the wife of a physician, NO ONE is entitled to healthcare. Like the rest of us, work & EARN it." "No one is entitled to the labor of another. Health care is not a "right" like freedom of speech or speedy trial."

      Civics lesson:
      Independent of society and relationship to other people, no one has any rights whatsoever. The individual in isolation has no restriction of action except that posed by the physical world. When two or more people are in proximity and therefore have the opportunity for interaction, they still have no restrictions on their actions. They retain complete freedom (but that includes actions such as stealing, maiming, tricking, and killing the other). It is in order to mutually avoid these events that groups of people agree to actions which are to be prohibited and others which shall be allowed with or without limitation. On a larger scale, the participation of every person in this type of agreement becomes technically impractical and unlikely. In that setting, history has shown us the evil that men will do upon each other and from that, we have reflected on what actions are central to our identities as happy individuals. These are things that have been found to be inherent to the human condition in relation to others, such as religious belief, the expression of ideas, and the pursuit of those things necessary for life (food, shelter, etc.). Even these things face restriction when they impact their same expression in others.

      Healthcare is a service that is provided through the cumulative knowledge, efforts, and technology only possible through centuries of collective human civilization and cooperation and is a service that only exists within the infrastructure that maintains that civilization today. It is almost impossible in this era to live in isolation, meaning that no one is living apart from this societal web. It is our collective imperative to decide, as a part of our societal contract, whether healthcare is a critical element that should be preserved for all, in some measure, as a "right."

      I think it is terribly difficult to argue that a valuable benefit such as healthcare, which has been the product of a complex, interconnected society inherently dependent on the cooperation of its members in myriad ways, should be available in a pattern that excludes any significant numbers of people. I am not alone in this and that is why almost universally ERs are required to service all persons who show up at their doors. ER care, however, requires extensive technology and critical care level services that are highly resource intensive (measurable in the amount that it costs). In contrast, preventative care services have been shown to accomplish a level of healthcare that prevents utilization of such resource-intensive services and results in overall decreased stress on overall societal healthcare resource utilization.

      Chronic and acute health issues from preventable diseases/conditions attributable to low levels of healthcare resource provision result in significant amounts of lost productivity in society as well.

      So no, healthcare might not be an inherent right (that is, if you're not religious, as many religious traditions endorse care for the sick). But we'd be absolutely stupid to not wish to provide it to all. You'd have to be completely ignorant of the fundamentals of human society, the political history of the world, the amount of healthcare capabilities today, and the dynamics of current healthcare provision.

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    15. Your statement is flawed. There is no hospital in the US that would deny emergency treatment on a patient. Even homeless people get treated in the ER, get admitted and have surgies eventhough they dont have any insurance and cant pay for it.

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    16. Dear dear civics lesson... There is a law passed during the Clinton years called the Emergency Treatment and Active Labor Act. I believe it passed in 1996. This law REQUIRES that all ER facilities treat all patients who walk in their doors regardless of citizenship, ability to pay, etc. in fact it is illegal to even ask them about any of those issues until treatment is being rendered. It is illegal to send them to another hospital, even if their insurance does not contract with the hospital they are in, if they require admission or are unstable. In fact, as outpatient care has improved over the years, virtually all patients admitted to the hospital are, by definition unstable. The only time you can transfer someone elsewhere is if the patient demands it or if the facility where you are lacks appropriate facilities or staff to address the patient's needs. So say you don't have neurosurgeons on staff, and the patient has an intracranial bleed that patient may be transferred to a facility with neurosurgery if that facility agrees to accept the patient and if the hospital has available beds in their Neurological ICU. The accepting facility is free to say no, however, if they do not accept the patients insurance or if they aren't insured. So then the ER doc is calling one after another facility until they find one to accept the patient and in the time it takes for that to happen. The patient may very well die. So the point is there is no usually abut it. Treatment is required by law all the time, regardless. Now what is law and what is right aren't often the same thing. Requiring someone to work for free or else face punitive action is in fact, slavery. Slavery. Give me one additional example in any industry where services are required to be rendered even if the service must be provided de gratis, and even more than that, you are held accountable to make no mistakes else be subject to loss of the ability to practice your art or be sued for damages in civil court. So it's more than whipping not only must you perform the service for free you must render it without delay, mistakes or any other violations of hospital, state, federal, or medical board rules. In other words, you may not be Human. I liken it to walking into the Porsche dealership demanding a 911 turbo and stating that you will not pay for it, give your real name so you can be tracked down for payment, and that not only do you expect to be given the car, you want the dealership to pay for it and take you down the street to Morton's for dinner. If the dealership refuses they will be subject to criminal negligence and violation of Federal Law. If you don't drive off in the 911 you want in the time frame you desire or if you didn't like your steak because it was cooked medium rare instead of medium, you sue Morton's and the dealership for "malpractice" of the art of cooking a steak, Morton's because they cooked the steak and the Porsche dealership for allowing you to be served a steak that was not cooked to your satisfaction. Sound ridiculous? So are the laws pertaining to malpractice and provision of gratis medical care.

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    17. Yes, they do. Because we made a decision as a society not to let people die in the streets and we passed EMTALA (an unfunded bill mind you) to guarantee that they wouldnt be turned away. But someone pays for that and that is the point! The surgeon will not be paid for that, the hospital will not be paid for that. But they both still have to pay their employees and bills that month and just eat that cost and/or pass it on to those who do pay for services through higher fees. This is exactly why everyone needs to have insurance. If you would agree that letting people die in the street is not something we should be okay with, then we only have 2 choices- 1. Continue with the status quo where the insured, the hospitals, and individual doctors already absorb and pay the cost of those with no insurance/money OR 2. We require everyone to gave insurance and help people obtain it. Either way we all pay our share, but ensuring people have preventive and emergency care is certainly more humane and economical that just payoff when someone is on deaths door and needs major, expensive intervention.

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    18. The only surgery a homeless person gets is emergency surgery to save their life. No elective surgery which is the vast majority of cases. If you are going to die from perforated colon you will get surgery. If you have a small cancerous colon polyp, good luck. In fact you won't even find out about the cancer until it is was too late because you cannot get a colonoscopy.

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  3. Brilliant response. This is one of those things that people often repeat without any proof (doctors make too much, doctors are rich). I don't understand our priorities: superintendents of terrible school systems make $500k, Sean Penn makes $15m/movie, michael young makes $16m/season to play baseball, Kim K makes millions for being famous yet we want to complain about what doctors make.

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  4. Well written and, sadly, true.

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  5. The biggest cost to the healthcare system, which no one wants to REALLY address, is smoking and obesity. It is actually the lack of accountability by patients and the litigious mindset that is driving healthcare costs through the roof. Blame your fellow Anericans who feel entitled without reason. Since a the majority of the voting public want their big Mac, fries, and big gulp, politicians will never actually address the problem...except maybe Bloomberg.

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    1. Yes, but then why do I see so many doctors and nurses outside smoking??? right outside the hospital doors....

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    2. That's the problem. The fact that the smokers wear long white coat and scrubs and wear a hat does not mean they are doctors. I am a physician too and totally appalled by it. Not that physicians dont smoke but most of those smokers are not physicians.

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    3. The problem with smoking and obesity is that the products that are consumed have been altered to increase addiction and habituation. Nicotine and high-fructose corn syrup not only fulfill a craving within the body, but they create it, as well. The reason that highly intelligent folks like doctors are outside smoking when their hospitals are smoke-free is that nicotine has a stronger impact on their brain than logic or even health-belief. The same can be said about the food we eat. We consume, but we dont get satiated, thanks in part to the manipulation of the product by an industry doing whatever they can to increase sales and profits, regardless of the cost. That said, the argument that personal responsibility alone and fix the problem does not work.

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    4. Actually, the number of doctors that smoke, on average is FAR less than the national average. According to a recent study, 2% of doctors, compared to 18% of the general public smoke.

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    5. No one, and I do mean no one, should ever be allowed to wear a long white coat unless the have an MD or DO and an active license to practice medicine. Period.

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    6. Fact: Obesity, Tobacco, and alcohol related care make up 40 percent of all us Healthcare expenditures.

      Dr. David Morse FACHE

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    7. And that is not something that doctors have done or have not done to our patients. We do everything in our power to get people to quit smoking diet and exercise. Here's an idea, measure a body chemical altered by nicotine and if folks test positive make their condition excluded from insurance. Sort of like a hemoglobin a1c for smokers. Make the Feds foot the bill for all tobacco related illness the reasonable and customary fee in tandem with RJR, and see how quick tobacco becomes illegal. You left out alcohol. Also micromanage employees health. Integrate health and exercise into the workday. Ethically questionable? Sure, but if the means justify the ends e.g. The greater good...

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  6. I love how you compare your job hours to pilot hours and then say they do a good job and are vital. However, you are hateful about nurses, our education, and the time we put in. Remember, while you're at home or in a call room sleeping a nurse is awake taking care of your patient. A nurse's job is vital. You are an OB. You know as well as I know how hard L&D nurses work. We are under paid and over worked and there is not a union in Texas. I do agree with most of your response except for your comments on nurses. You need to say thank you every once and a while and give credit where credit is due.

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    1. I don't think he was putting anyone down; he was just stating a fact that we work hard. Most of our jobs are not shift work; have you ever did a 30-hr call and still expected to be completely functional. We all have made decisions about our careers and I admit that without my nurses, I cannot survive. Sounds to me that you have an inferiority complex when it comes to physicians; not all physicians disrespect the ancillary staff just like not all nurses respect physicians. The main issue here is not someone slamming nurses but rather providing vital knowledge to the general public that when you account for all the expenses (college, medical school, loans, family, etc) along with delaying your life for 8-10 years, physicians don't truly have it as easy as people think.

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    2. He was not hateful towards nurses. Nowhere did he say that nurses were lazy or not "vital". The issue here (and I believe part of what he was attempting to address in this letter) is that you seem to equate the statement of "less than" with "not good". This is simply wrong. But in doing so you expect to NOT work as many hours and still be spoken of as if you do. The reality of the situation is that nurse training and scope of practice is not nearly as extensive as that of physicians. It is, in a very real sense, a support role. Just because *A* nurse is awake taking care of his patients while he is asleep in the call room doesn't mean that this nurse has worked as many hours as he has. How many nurses are on call? To be perfectly frank, there isn't a nurse in the country who works as long or as hard as residents do (which was the actual subject of the statement he made - residency) because... it simply isn't allowed. Every hospital I have worked in has very strict hour caps on nurses. Meanwhile legislation is passed to cap resident hours at 80/wk (or as residents like to call it - vacation)

      So please, do not come in here and attempt to straw-man your way into an argument. The author was quite accurate in his statements.

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    3. Why anytime anybody says anything about how nurses don't go through the same training physicians do they get pissed about it? Was anything that he said not true? It all looks pretty accurate to me.

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    4. Valenti was not at all disrespecting nurses in his editorial. I don't even know how you came to that conclusion. ALL he stated was that the length of education + training is not the same for an NP/PA vs. M.D./D.O.

      Dr. Valenti, THANK YOU for speaking about the exorbitant cost of medical devices and supplies. No one EVER raises that issue when discussing healthcare costs. My practice is very close to losing money for each Thoracentesis we perform. If reimburesement is cut at all, we WILL lose money. And does that dime sized plastic connecter for my polysomnography equipment need to cost $50? I'm relatively certain it does not.

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    5. As a current student in CRNA school I would put any of my classmates up against most residents. It's the belittling of the NP education that is uncalled for. As he said there is a huge shortage of providers so therefore he should be embracing the NP's and not down playing their vital worth. Yes they may have not have a "residency program" but where I work they do 24 hour shifts and actually have experience coming out of school rather than being completely worthless their first year. By having NP's enter the field it takes off the stress regarding a lack of PCP's and for most MD's...increases their paycheck. I think its a win-win situation.

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    6. Yes I have done 30 plus hours of on-call. I was a hospice nurse. No inferiority complex here. By your suggestion of that it is apparent that you enjoy imaginery power trips over the "ancillary staff". I didn't appreciate his tone while he discussed nurses. That's all.

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    7. I read his statements the same way she did and her response in no way lead me to believe she has an inferiority complex. I am sorry female physicians have to hold off on having families but that is the price you must pay if you want to become a physician. Nurses give up weekends, holidays and much of their lives to also serve so please don't say we feel that we are inferior but understand that we are also deserving of appropriate pay for our time and efforts.

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    8. So true.
      Nurses do a good job but ure on shift... and ure under ur doctor's insurance who is on call after 30hrs so who takes the hit when it all goes down.
      and its stated fact. You dont have residency. 2yrs in grad school after 4yrs undergrad and u pass boards go independent.
      You do an amazing job and your job is no joke either but lets start been honest, these docs who soo much more.

      delay life 8-10yrs... i think its more than that even. And when you're done, esp as a female.. u realize ure single and kinda too late to be dating even....

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    9. Nurses are important, yes. That wasn't the point.

      The last time you worked a 36 hour shift was????
      Doctors sleep in the call room because that may be the only hour-long nap that they get for a few days and nights. Sheesh.

      He didn't disrespect nurses, just said the education isn't the same. It isn't even close. Period.

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    10. I agree that nurses work hard. Very hard. And don't get paid enough. However I would agree that the sleep debt, monetary debt, and lack of shift work make being a physician an extremely difficult job. I love my nurses, I treat them all with respect, love, and friendship. But the level of commitment, responsibility, and the sheer number of years we give up to get to a professional level just aren't the same. I suspect that is the point he was trying to make...

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    11. Thank you for your reply to this person's complaint and I, as an RN with 26 years experience, including 10 years Critical Care, agree with Dr. Valenti's article. When people think of "rich doctors", I believe they are referring to big city plastic surgeons, who mainly take patients who can pay. And I say that not to diminish them...I look forward to my inevitable mini-blepharoplasty!
      But please, please do NOT refer to Registered Nurses as "ancillary staff"! I believe that refers to non-nursing, often unlicensed support staff. We do not go through as much training as MDs, but we do have quite a bit of training, and frankly, most of it is "on the job." It takes years to become an expert nurse, experienced enough to keep your patients alive until the MD can get there. We work as a team and I, as many, enjoy that relationship. "it takes a village..."

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    12. The author is responding to the calls from our brilliant president's advisors for nurse practitioners to take over huge pieces of the healthcare market to cut costs, under the assumption that NPs are "the same as doctors" and can handle anything that a residency trained MD can handle. He is not discounting anything nurses do, just saying the levels of training and time invested are much different.

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    13. Excellent letter and I agree so much with all of your points regarding physician's salaries. For all of the education, training, and level of expertise, many physicians are sorely underpaid, especially when compared to that of many athletes and/or entertainers.

      I am an NP (18 yrs RN, then 8 yrs as an NP). I am currently, and have worked with many amazingly talented, caring, and highly educated & experienced physicians. Quite frankly, there are times that I don't think any salary could compensate the service they provide fairly.

      I do feel, however, that some clarification needs to be done regarding nurses & NPs.
      RNs scope of practice is clearly defined by each state board of nursing, and no nurse I know will ever fill the role of a physician. In many states, NPs do have a scope of practice similar to that of a PCP. According to current literature, however, an NP is required to have at least 5 years of nursing experience, a master's or doctorate degree (with at least 500-600 clinical hrs), and national board certification. The majority of the NPs I know have had at least 10-15 years of experience, even prior to beginning their NP education/training.

      It would be great if everyone would stop looking at nurses as "junior doctors". Nursing is it's own profession, unique in it's education,training,role,and responsibilities. My goal is only to be the best NP I can, not to be or replace a physician.

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    14. I personally didn't perceive any hatefulness towards nurses in this article. Simply bringing to light that the training requirements are not as extensive for nurses or even physician extenders. It's just a fact.

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    15. It seems like every time a doctor defends their profession or career, there is always one nurse who posts something like this back. The converse, as far as I know, is rarely true. I just finished a standard work day: 5am to 12mn. During that time I have seen three shifts of nurses take care of my patients, and I didn't sit down to eat or take a scheduled break all day. My last day off was 2 weeks ago. Compare that to an RN that makes twice as much as I do (I'm still in training) and works 3 12 hour shifts a week. What a joke. I love my nurses, especially my ICU and RR nurses. The 1% who troll the message board to rag the doctors really give the profession a bad name. So sad.

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    16. "I love how." Take the passive aggression elsewhere. I respect nurses. Not "my" nurses as the post above me says, but ALL nurses.

      With that said, I haven't done your line of work so I can't comment on its rigors, however you haven't done our's so you can't downplay our efforts either.

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    17. I believe the commentary about nurse and nurse practitioner training was in response to the common argument that mid-level practitioners can serve the same role that physicians currently fill. It is not meant to imply that nurses are in any way less crucial to the healthcare system, but simply to emphasize the difference in roles. The argument goes two ways; physicians would be woefully inadequate in performing many nursing duties, just as nurses are not trained to fulfill physician responsibilities.

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    18. Of course, it's all about the nurses. And while the lazy doctors sleep (what hospital are you working at...you mean catch 30 minutes of shut eye in the middle of a 30hr call?!), some nurse on shift call does all the work and of course carries all the responsibility. We get it. Credit where credit is due - sure. Nurses job is vital - how could anybody forget. We all know how hard you work - of course. Underpaid (six figures for three shifts/week) and overworked - certainly. I think all doctors should stay home for a while and just let the nurses run the healthcare system by themselves for a week or three so nothing gets in the way of the RN self glorification...

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    19. agree with above. RN does not equal MD. just think about how much work you have turfed off to your "relieving nurse" at change of shift, break, etc. For docs, there are no breaks. there are no relieving staff.

      Know you role.

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    20. The previous article does not belittle anyone who carries a RN. Nurses and nurse practitioners still work under the scope of a supervising physician. The reality is beyond the time we spend in the hospital during residency, we are essentially students at home. In order to adequately do right by our patients, we spend outside hours uncompensated to expand our knowledge base to better serve not only our patients but our ancillary staff. We work as a team, respect one another, rely on each others experience, but doctors take the brunt of the responsibility BECAUSE of medical school and residency. We are expected to be continually educated, maintain good rapport with patients, make life altering medical decisions that should they be wrong - place our worthwhile/means of living at risk. The ACGME states we are to only work 80hrs, but unlike the rest with shift work, this internal medicine doctor is always willing to answer pages, read more scientific articles, and find available resources for patients in need - even after a 30hour call.

      Balance a large debt burden, a risk job setting with palpably fatal results, public perceptions living the rich life when your paycheck goes to student loan companies while the majority of the friends you've grown up with own property and have families - put these all on your shoulders you too will feel the pain and anger when someone tells us we get more than we deserve.

      I grew up raised by a low income family, clawed my way to medical school, residency burdened by debt- and for what, being part of a profession where my job allows me to be part of a group of people that aid the sick, not because I have to, or any oath I took in school, but because it is what fulfills me.

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    21. Wow people! Back off! It just goes to show how little people in general know how an RN goes on to become an NP. Years of training. I'm not hating MD's there are many that I love and are dear friends. I really just didn't like his tone. I especially love the replies from the residents. July is the most dangerous month of the year in teaching hospitals! I've worked in two of them. I guess I'll just have to shrug my shoulders and walk on when one of the all knowing residents asks me, a lowly RN, a question their attending expects them to know. Good grief. Also, I do not know a single RN that makes a six figure salary working 3 shifts a week. I wish! Someone lied to you. Also, stop saying "my nurses." Do you own them? I'm guessing no. Respect goes both ways. I chose not to go to medical school as a lifestyle choice. I wanted a family and wanted to be involved as much as possible with my children. I've seen many of my friends who are MD's struggle for family time. I enjoy being a nurse and I'm good at it. I also am able to have a life outside of the hospital. RN is not what defines me.....it gives me group health insurance so I can afford to see an MD when needed.

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    22. As an OB, I appreciate the work a nurse does, they are my first line of caregivers. However on a call night when I try to take a quick nap between patients, they dont seem to understand that I have to get up and go back to work in the morning and see patients until 6 pm while they go home after their 8-10 or maybe 12 hour shift.
      I don't believe Dr Valenti meant any disrespect. You guys do an incredible job. I think he is commenting on education vs pay.

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    23. Nowhere in this is he hateful to nurses. My mother is a nurse, my friends are nurses, and I started out as an EMT/patient care tech prior to going to medical school. I am in my final year of residency, and I will be the first to admit that I rely heavily on the nurses. They have a wealth of experience, teach willingly (without throwing it in my face, as some commenters above would seem wont to do), and I'm not ashamed to admit have probably kept me from making some serious mistakes.

      I would like to emphasize the word EXPERIENCE in the above sentence. As physicians, we complete undergrad, then go to 4 years of medical school, and THEN enter into the clinical world of residency for 3-7 years depending on speciality. The nurses we work with and who teach us the most have been working in their field for much longer. To the commenter who is in CRNA school with an apparent chip on their shoulder, who would "put my classmates up against a resident any day," let's level the playing field. To become a CRNA, you must have extensive nursing and critical care experience and your BSN before you can even start the training. So after obtaining your license, you already have years of experience we don't start with.

      I am in no way belittling CRNA's, NP's, or RN's. CRNA's taught me to intubate during my anesthesia rotations. The nurses I work with continue to save me, teach me, and mold me into a better physician. They interact with patients more, carry out all manner of orders, endure disrespect from patients, family, and physicians alike. I will always believe they are underpaid.

      I am sorry to the future CRNA and frustrated nurses for being so "useless" my intern year of residency. I didn't realize all brand new nurses were bastions of clinical competence when they start practicing. I'm sure your first year of nursing you never made mistakes, you were never terrified of killing a patient. I was petrified my first night alone. However, I had the sense to admit it.

      In addition, the commenter who notes that a nurse is awake at night taking care of my patient while I sleep in a call room, clearly has no idea what 30 hour call is like. There is a big difference between being on the night SHIFT, able to page the doctor for questions/orders and having to make the decisions while desperately trying to get any sleep because I've been there since 5am and still have to round in the morning. Also, just like you have more than one patient, so do I, each of whom has a nurse taking care of them, who pages me when he/she needs me.

      Finally, physicians also routinely work nights, weekends, holidays. We take our work home with us, even when we're not taking calls at home. We stay awake at night, wondering if we did the right thing for our patient. We spend countless hours outside of work studying to stay current. All of this takes a huge toll on our loved ones, who also expect our time.

      I will also touch on the much bemoaned topic of the sacrifices made by female physicians. Simply: may those of you who are so flippant about it have a daughter who chooses that path. Perhaps your perspective will change when you watch her go through it, maybe you will be less likely to give that female physician a hard time or derisive treatment. Try envisioning that tired female voice on the other end, or that hands-shaking nervous female resident, as your daughter next time.

      NO ONE IS SAYING NURSES DO NOT WORK HARD, except a few morons. However, at the end of the day, physicians go through more schooling, complete a residency, and shoulder the ultimate responsibility and liability for patient care. So enough with the doctor bashing already. While I cannot apologize for the ills of my predecessors, and am in no way seeking absolution for bad behavior or mistakes, I am tired of being made to feel guilty for admitting that I expect compensation proportional to the skills I provide. End rant. I'm off my soap box now.

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    24. I will be a doctor but I am the son of a CRNA. I can tell you that my father who has worked on-call every year for the last 20years has put in more hours then a lot of doctors. The OB doctor at his hospital might reach my dad's hours but thats it. Even when he is not on call he can end up working 60-80 hours. Most of the time he gets no break during regular work hours and lunch is one bite on the go. in fact he had an 80+ on-call work week followed by a 60 hour off call work week. He also gets no respect from many doctors and administrators because of the RN in CRNA yet every single doctor wants him working their surgeries. He gets up and starts work around 6 or 7 everyday he works and half the time doesn't get to go home till 6-8pm.
      I do believe most doctors do deserve to make more money then the rest (the exception being an anesthesiologist as most don't do crap and are paid on the backs of CRNA's. I will never let one touch me. The best thing a CRNA can do is find a hospital that doesn't have one) but their are many andvanced nurse practioners out there who are underpaid. Fact is nurse's and doctors are all important and deserve respect and Dr Valenti's rebuttal was very good but some of his facts were a little off.
      If Americans really want to lower the cost of healthcare for themselves the best thing they can do is develop semi-good eating habbits and above all they can exercise.

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    25. Yes, but the nurse works a shift. The doctor is "on" whether he happens to be lucky enough to sleep or not. He or she works all day then takes call at night and might have to work the next day too.

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    26. As a physician I recognize the benefit of nurses and their value in the healthcare environment of the future. This article isn't about nurses. Simply, the article is about defending the allegation that physicians are paid too much. It is unfortunate that the question of the nurses value has been raised. The main issue is more about when so many others are able to end a shift, the physician typically must continue until the care is complete. Many nurses are also in this situation, namely the hospice nurse.

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    27. How did we get so far away from the point? I agree that nurses work hard. I know that they work hard and are vital to the healthcare industry. I do not think anyone was disputing that nor were they taking a stab at nurses in any way. Any yes the debt from medical education is high. Actually today it averages 250K to 300K and there are now limited options for deferment of your loans. Unfortunately, making payments on loans as well ,as general life needs, during med school, residency and fellowship where you may make on average 35-38K starting out is difficult and many take out further loans. The hours are terrible and often it is not limited to 60 hours/week. Last week along I put in 123 hours. Yes, count it up, that is in excess of 3 full time jobs. Why, you ask? Because my patients needs dictated that I be there and that is what I do because I made a committment. That is what we do as physicians. Most average 3-4 years of residency after 4 years of medical school which follows 4 years of undergraduate school. Try 15 years total, for instance, in my case. I am not trying to toot my own horn but rather provide a point of reference for those who may not otherwise know. We do not all play golf in the am and work "bankers hours."
      I am in total agreement that physicians are under respected in this culture and certainly DO NOT contribute significantly to rising health care costs. In fact, when you caculate it up on an hourly basis physicians live below the poverty level throughout med school and residency only to come out of training several hundred thousand in debt and find an ever increasing inability to recover their losses in this economy. So think about these things before you go spouting off about how we make too much and just remember that while we are attanding to your needs we are very likely to be sacrificing our own as well as the needs of our families.

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    28. This article isn't about NP/RNs but when he starts out with a negative tone whilst tossing the nursing profession under the bus…it is quite difficult for those of us who spent 6+ years becoming NPs. If we are going to compare educations why not compare paychecks too? I see as many patients as the MDs I collaborate with but, his paycheck is three times mine but, I bill for 85% to his 100%…huh, Dr. Valenti, talk about under paid.

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    29. 500 - 600 clinical hours for NP training, um... that was the first two months of internship. The NP students rotating on my practice as a hospitalist function somewhere around the level of a third or fourth year medical student. Come to think of it, physicians have more clinical experience at graduation from medical school.

      I read somewhere that the minimum hours of education and training required to be minimally competent to sit for the internal medicine boards is 39 thousand hours, 59 thousand for thoracic surgery. That is counting from the time starting a bachelor's degree.

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    30. Did someone seriously suggest that an NP should be paid the same as a physician? With all this talk of disrespecting the nursing profession or not giving nursing its due, it seems that some members of that profession have no problem throwing physicians under the proverbial bus.

      Midlevel providers in general are a HUGE asset to healthcare. However, they do not require the extensive education in science, pathophysiology, etc that is part of a 4 year medical degree. Further, they do not complete residencies, so they do not have specialized or procedural training. They learn about their chosen field on the job. (I am in no way devaluing them or the knowledge they gain, before someone jumps down my throat)

      Several of my friends have just made the jump from nursing to NP and are choosing their career paths. They are choosing ortho, GI, vascular, FP. There is no residency required of them, and should they choose to change fields, they may do so without any formal training. Ortho is a 5 year residency, often followed by fellowship of 1-2 years; GI requires a 3 year internal medicine residency plus a GI fellowship; vascular surgeons complete a 5 year general surgery residency before doing their fellowship.

      The thousands of hours of training, ultimate liability, and responsibility are why physicians are paid more than midlevel practitioners. You may see as many patients as the physicians you work with, but they are still ultimately responsible for the care your provide.

      Finally, for the sake of everyone's sanity, please re-read the article. He is not disregarding the nursing profession or NP's. HE LITERALLY MENTIONS NURSING/NP'S IN 2 SENTENCES ONLY. The actual focus of the article is pointing out the gross misrepresentation of the rising costs of health care in this country and their alleged causes. He is simply pointing out that physicians are not the cause, and makes the apparently horrible mistake of making comparisons to other professions.

      It seems that whenever someone attempts to explain the commitment and contribution made by physicians, there is always a minority that seek to vilify us or somehow turn it into a doctor vs. nurse fiasco. I ask the nurses who have been offended by this response letter to actually read the original commentary by Mr. Leher. In it, he attacks all healthcare workers, INCLUDING NURSES, even the janitorial staff, stating that they are overcompensated.

      He goes on to say most nurses make $70,000+. I don't know many RN's who make that kind of money without being superspecialized or working massive amounts of overtime. Not only does Mr. Leher state you are overpaid, but he grossly misrepresents your salary to the public while dismissing your education and clinical accumen as "only an associates degree."

      Is the nursing profession underpaid and underestimated? Absolutely. Should you be furious? Yes. But pick your battles as well as the appropriate context. People like Leher are questioning your merit, not physicians. I don't know a single physician who would devalue nursing like that, let alone in print.

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    31. The point that I was trying to make was not MD vs. RN, although I guess it has come to that. I really just didn't like how flippant he was about people who work so hard. It irritated me that he gave pilots due praise but threw the nursing profession under the bus. That is all. Yes, we all work hard. Yes I have done long call hours. Try Friday at 5p through Monday at 8a. No I do not make $100,000 + for working 3 shifts. This shouldn't be a debate. I just thought it should be brought to his attention to not be so dismissive about nurses.

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    32. He is not bad-mouthing nurses! The fact of the matter is you do your 12 hour shift with one or 2 patients to care for and then you go home. Your job is vital and important he is not saying it's not he's addressing a totally different subject.

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    33. Reply to - AnonymousAugust 2, 2012 5:48 PM

      From my personal experience as an attending anesthesiologist just in practice for the past 3 years- there are good CRNA's but very few. Most of the cRNA's can do a routine ASA 1-2 case without a problem Anesthesiology is very safe now a days. However, give them an ASA 3-4 patient and I bet you there will be many mistakes- inadequate preop, vital info missing from preop, treating hypotension repeatedly with pressors instead of trying to identify and treat the cause, taking patients to elective surgery without pacemaker interrogation, inability to place regional blocks and central lines, no authority to question the surgical attending when a certain management may not be in the best interests of the patient, - good example- one of my CRNA's missed a grade 3 systolic murmur on auscultation! They just don't have the breadth of knowledge to safely manage patients without MD supervision. You can train anyone to put in an ET tube and take it out. But you need real physicians to really understand complex medical problems. Yes, there a good CRNA's who can mange that, but very few. If i give the option to our CRNA's to practice independently, may be 10 percent would accept. Rest of them don't have the confidence, which is good- they know their limitations. Better that than an overconfident CRNA who thinks they are equal to MD's.

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    34. To the self-righteous pre-med whose father is a CRNA: why not put your money where your mouth is and go to nursing school? You could save yourself some time and money while you're at it...

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    35. Also directed at he who "will be a doctor". Good luck with that. I wouldn't count my chickens unless you know you are going to have a diploma in hand. A doctoral degree in hand is worth far more than playing doctor. Earn it, then spout all you like. I had classmates that never made it past year one, or year 2, or year 3. Some didn't make it through 4th yr, some didn't make I t through intern year. Some didn't pass the boards and some died before they even finished their training of cancer or trauma.

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    36. I was really excited when I stumbled upon this article...then very dissapointed when I started reading the comments. Just to reiterate, this article has nothing to do with nurses. It was just a comparison point on the length of education which any rational person cannot disagree with.

      The fact of the matter is nurses are a very vital part of our healthcare system. Dr Valenti, never says otherwise and never bashes the nursing profession. They provide the a level of care that a doctor cannot because a doctor has too many patients to spend that kind of time with each individual. Physicians need nurses and nurses need physicians.

      Physicians chose to put in the time in undergrad, in medical school, in residency and will continue their education for the rest of their lives. Nurses just don't do that. That was the only point he was making.

      Please take this article at face value and not nit-pick the nuances. Realize that there is something drastically wrong with our healthcare system. That the physicians are the ones being thrown under the proverbial bus by investors and insurance companies and pharmaceutical companies so that these latter groups make the money. The doctors who invest their time to improve the quality of life of Americans have taken a paycut when you take into account the education and hours worked. Frankly many physicians are taking paycuts to keep their nursing staff at their salary so that they keep their practices going. Physicians will continue to make such sacrifices as they are paid less and working more. There is a shortage of doctors and there will continue to be a shortage unless many things change. Graduating medical students will continue to go into specialties that pay more instead of primary care because of their loans from undergraduate and medical school. Many things must change, including a physicians pay.

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    37. Also to Mr. I will be a doctor-

      1) Learn to spell. Use proper grammar.

      2) If you plan on addressing the adults in the room, you best act like one, instead of the petulant child. You are either not in medical school yet or at the very beginning. If you don't check your attitude, something tells me you will have a very difficult time getting into a residency program.

      3) The "my dad/mom is an RN/CRNA/etc" line gets old, fast. The nurses (and CRNA's!) do not care. They would prefer you to be respectful, competent, and a good physician. Its wonderful that you will start your medical career wth a unique appreciation and enthusiasm for the nursing profession. That can't be taught, and sadly, some physicians opt for an adversarial relationship. HOWEVER...

      4)Your father's years of clinical experience do not magically transfer to you, nor do they validate you in any way. They certianly don't qualify you to make any sort of informed statement on health care or medical practice. Daddy's not going to get you into medical school,junior. What's next? Are you going to start telling all of us that your dad can beat up our dads? I'm fairly certain your father would be mortified if he read your post.

      5)This is just to further address your glaring ignorance. I don't even know how to put into words how offensive, pointless, unfounded, and out of touch with reality your little statement was.

      Finally, in the immortal words of my late grandfather, "Pipe down pipsqueak."

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  7. peoople read "news" like this and either believe it, or don't believe it, but it's not a lack of information behind it. this isn't ignorance- it's much, much worse. author is VP of the Heartland Institute which is one of many media fronts we get our "news" from every day that exist simply to promote the interests of thier funders. heartland institutes funders include GSK, Pfizer, Eli Lilly & other major players in healthcare. sham articles like this this appear on the pages of legitimate papers every day. it has nothing to do with controlling healthcare costs or facts. it's to publicly vilify docs & mislead anyone who reads it in an effort to maximize profits for his billion dollar corporate sugardaddys. not convinced? this group is also the leading voice in anti-global warming "research" & vehemently argued against adverse health effects from secondhand smoke. is it conicidence that two additional sources of their funding just happen to be Exxon-Mobil & Philip Morris?

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  8. Thank you Dr. Valenti. I can't tell you how many times I've heard people ignorantly trash doctors as if they were the source of all the problems with healthcare in the US. It is extremely refreshing to hear someone speak up for doctors everywhere and tell people the truth about the problem.

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  9. I have to point out that nurses may not go through a 'residency' but most of the NP's I know have years of experience under their belt and further, many NP programs are now Recommending doctoral level education. By the time I am finished with my DNP I will have seven years of school and eleven years of clinical experience. I realize the point of the article is to show how hard drs prepare for their careers but please don't try to minimize the efforts put forth by NPs!!

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    1. Please, tell us about the courses you take during this doctoral program. I am sure they are very strenuous and not fluff with the soul purpose of taking your tuition money at all.

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    2. "Doctoral" courses does not make one a doctor able to take on MD/DO duties...otherwise PhDs would be able to take care of the sick as well.

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  10. Well worded article. Not even mentioned are the ridiculous malpractice premiums that have been skyrocketing due in large part for the grossly unfair legal system that is heavily skewed in the favor of ambulance chasing attorneys. Few, if any other profession is targeted by attorneys the way medicine is. Most physicians have been sued if they have practiced long enough. This accounts for the practice of defensive medicine which is a huge component in the cost of health care.

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  11. The general public has no idea the amount of time, training, and dollars that go into each physician. They work extremely hard for 4 years of medical school, a few years of residency, then fellowship, THEN they make a decent salary but still have to pay the 150,000 they owe in student loans. Furthermore, the greatest sacrifice of all, their 20s.

    Excellent retaliation to a ridiculous article. Funny how this article will be different in 10 years when nobody enrolls in med school anymore...

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    1. Thank you Kate! I totally agree. What a huge commitment (11-14+ years) to take care of patients not to mention the incredible debt physicians have!

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  12. Thank you for writing this on our behalf. We need more people like you to speak out about this travesty. I am a resident in Family Medicine at one of the busiest public hospitals in the nation with a medical school loan debt that is now over $300,000. Between the hospital going broke, and my residency program and patients having to cope with constant cuts in funding and resources, things sometimes look very dire. But, when people ask me how residency is (almost sarcastically), I STILL can't wipe the smile off my face when I tell then "I LOVE MY JOB!"
    There is nothing like making a sick, suffering person feel better. It's not a "God complex," it's the sense of satisfaction that we get when just ONE patient out of a hundred looks at us and says "Thanks, doc."

    -Dr. C

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  13. Sadly, I had to find a new family practice physician after nearly 20 years. I had been with my physician since he began practicing. He was extremely well read, spent time getting to know me, and genuinely cared about my well being.
    He changed his practice to concierge practice--preventative health, as much time as you wanted to spend with him--basically what I had always felt he had done for me over our years of association. The difference was there was a significant, non insurance reimburseable annual fee.
    When I asked him why he was doing this he was very candid in saying he wanted to practice medicine. Over the years he had been pressured to hire more staff to ensure that he was in compliance with insurance requirements, hippa and other regulations. In order to make a living for his family his choices were to become a "patient factory" or do what he did.
    My hat is off to him.

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  14. As a med student I was shocked at the ignorance of this article. And I'm glad a doctor responded. I dont think we are talking about the issue that this country is facing. In 20 years who will be left to take care of us? 10 years even. Even the doctor who wrote this will probably retire in 20 years. And I'm telling you no one from my class wants to go into general care because we have loans and bills to pay. They are not making enough. That's the truth.

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  15. This article would have been great without the last paragraph. It weaken his credibility.

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  16. Not to weaken the article, but United Healthcare (Symbol UNH NYSE) paid a 1.2% dividend which is lower almost any good AAA corporate bond.

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    1. Not according to US News and World Report. they listed UHC as the most profitable Health Care Company in the US

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    2. They might be profitable, but I bet many others operate at higher profit margins.

      It still doesn't change the fact that their shareholders got a 1.2% dividend, the article stated it as 11% which would be outrageous by any account and implying that it was rewarding shareholders by squeezing physicians. It's like saying the government was taxing at 33% rate while the real rate by 3.3%.

      Its common for some companies to have high yield margins the best examples being cigarette companies, top advertisers like Google and consumer conscious companies like Apple. Because insurance companies are huge financial speculators, they usually have a large cash reserve so they don't go bellow up if something goes wrong *cough* AIG *cough*

      This is not to make an excuse for them, but my point was the article makes it sound like they seem like monsters are ripping off doctors for shareholder expense by giving a 10+% dividend yearly (considering the number of share would be huge would be $5+ billion at current prices) while they might be ripping them off, its not to enrich management or shareholders.

      He has to find a better reason supported by data. You can't just make those things up.

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  17. Darren Gatewood, RN, CEN, CPENAugust 2, 2012 at 9:59 AM

    Very well written response to a horribly biased and misinformed article. As Dr. Valenti stated, the cost of medical equipment and medications are drastically different in the US. Also, the American idea of "sue first, ask questions later", forces our hand to practice medical-legal medicine. EMTALA laws require us to provide care to everyone, which frequently results in free care given by emergency rooms to those who should be going to clinics. Governmental regulations such as HIPPA and The Joint Commission, while they have good intentions, bloat healthcare greatly.
    I'd also like to add that as an RN, I saw nothing derogatory at all with Dr. Valenti's statements about RN and/or NP education or abilities. We have nothing resembling the residencies that physicians go through, which is truly what makes a doctor. I have over 16 years experience working in ERs, and almost every day, a physician catches something that I would have missed.
    Physicians deserve what they are paid, and deserve much more respect than they are given in today's society.

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  18. Well stated, thank you for replying!

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  19. This MD needs to get his facts in order. Most people will read this article and say "wow" this doctor is speaking out. However, a lot of his facts are wrong. Furthermore, while MD pay in Germany might be a higher %, the overall health of German people is a lot greater than that of the US. Also, the costs of the procedures are less expensive (see this chart from the washington post--http://www.washingtonpost.com/wp-srv/special/business/high-cost-of-medical-procedures-in-the-us/) so it is interesting to argue both sides

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    1. The author is talking only about the extent that physician salaries contribute to the cost of healthcare in the United States, citing it as a % of the overall cost of healthcare. The other points are irrelevant.

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    2. when we were fighting payment at dr.s office for resonable and customeary charges we kept asking what did that mean finally we were told by the insurance company that those were the charges that were out into effect in 1976 and had not changed so if anyone wants to change those that is where they need to start.

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  20. Let's set the record straight: this isn't ignorance, "liberal media", (as some have commented) or an op ed piece. author eli lehrer is former VP the heartland institute which is a nonprofit claiming to promote "research", most of which is biasly conducted by the corporations which fund his group. this institute is just one of one of many media fronts we get our "news" from every day that exist simply to promote the interests of thier funders. eli's strong opinions about healthcare workers' salaries are not really his opinions. he's a puppet for his funders, which just happen to be GSK, Pfizer, Eli Lilly, as well as insurance giants. (it's interesting that he doesn't mention this in his "article"). sham articles like this this appear on the pages of legitimate papers every day. he knows the facts. he understands that docs' s...alaries are 8% of expenditures, yet it's the title of his "article". he obviously has no interest in controlling healthcare costs or facts. the article's designed to publicly vilify healthcare workers & mislead anyone who reads it in an effort to distract from the profits of his bosses (who don't provide healthcare, yet make billions). it's time we wake up & stop allowing this kind of propaganda on to the pages of "legitimate" sources of media, and "Dallas Morning News" just happens to the biggest paper in dallas (250,000 subscribers). and let's just assume his funding is a conicidence and act as if this was written because eli believes the cost of healthcare would be lessened if we cut salaries for the greater good. it might interest you to know that heartland institute is the leading voice in anti-global warming, not to mention that they vehemently argued against adverse health effects from secondhand smoke. is it conicidence that two additional sources of their multimillion-dollar funding just happen to be Exxon-Mobil & Philip Morris? we need to start demanding better, and stop reading articles written by fraudsters.

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  21. Dr. Valenti's points hit the nail on the head, all of it. Thank you!!

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  22. Additional points to be made: Although physician "salaries" may make up only 8% of health care costs, the legal requirement for corporate health care insurance plans is that only 80% of insurance money collected has to be paid out for health care, while 20% can be allotted to administrative fees, which includes the $3 million to $7 million salaries of corporate CEOs, (e.g. Humana, CIGNA, etc) who are the ones REALLY skimming the system way beyond what is reasonable, IMHO. Imagine making $3 to $7 million bucks and not seeing even a single patient!! The current corporate system allows this, and the people on the the Boards of Directors of these companies, and their corporate salary committees, all are enriching themselves, while people still pay an arm and a leg for medical care that is supposedly "insured" due to system-wide abuses of co-pays, etc. Don't direct your complaints to the doctors who have lost control of medicine in the US; instead direct it at the corporate practice of medicine, insurers and health care corporations. Don't just add in the salaries of the CEOs, but also the Corporate VPs, Treasurers, Regional Directors. Go to Yahoo Finance, click the symbols of such corporations and then find their annual salaries PLUS their STOCK OPTIONS. Many of them make in ONE YEAR what i as an academic Emergency Medicine physician have made IN MY ENTIRE 30 year- CAREER!

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  23. I am a physician and have practiced primary care and hospital medicine for approximately 10 years. During this time I have mostly served the neediest patients in the most medically underserved communities. I make less money than physicians doing the same work made in 1970. My jobs demands have nearly cost me my family, my health and my life. I had to foreclose on my house because I suffered a nerve injury to my leg exacerbated by my job and long hours of standing. I used all that which I had saved to support my family of 4 while I recovered. I 1/2 years later I returned to full time medical practice and simply could not handle the work load, physically and emotionally. Lacking much support from colleagues or family members, I began to seriously consider self harm. My story is not unusual. I happen to be a brilliant and very well trained diagnostician and my patients over the years have adored me. I have saved countless lives and caught many diagnoses that had been missed by others. If the current trend continues in terms of popular perception of what medicine is versus reality many, including myself will leave the profession. The best and brightest are already finding success in other careers, and I hear stories daily about other business ventures my smartest most elite trained colleagues are actively engaged in. America, you get what you pay for. If you have decided health care is not important to you, I hope the payments you made on your fancy cars brought you enough joy to offset a premature death due to a treatable condition that was not detected or well treated. Speaking of which, I am 43 and have not had time to establish with a new physician ( my old doc was forced to go concierge by her institution and I can't afford to see her). I have not had a mammogram, since I have no one to order one for me. Many doctors are unable to take time off work to care for themselves and statistics do show that Physician's have a much shorter life expectancy, and female primary care doctors in particular have some of the highest suicide rates amongst physicians. We are forbidden by law from unionizing, striking, or doing walk outs. We are required by law to treat anyone who walks in the ER door regardless of their citizenship or ability to pay. 80 work weeks are the norm for primary physicians. Would you want to be a doctor? Chances are you would not. Guess what, graduates of college agree. There are fewer and lesser quality people going into medicine today and most choose a specialty. Medicine as we know it is dying, so you had better live well. I think hospice care is the future of medicine in the US.

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  24. I am a board certified physician in solo private practice since July 1987. I have seen my Medicare fee schedule decline around 70% on surgical procedures, without compensatory increase in my medical office practice portion. Private insurers have decreased their fee schedules to below the Medicare fee schedule level (for 2012) by anywhere from 13-30% below for BCBS of TX, to 25-35% for United Healthcare, to 25-40% for Aetna. Solo practitioners have no bargaining power with the private insurers. The Texas Legislature further reduced the payments for Medicaid in 2012 and totally eliminated paying their 20% copay for Medicare/Medicaid patients. I can't afford, as a solo practitioner, to participate in the private insurer's plans because they don't pay enough. I have told my Medicare/Medicaid existing patients that I will continue to take care of them, but counsel them not to try to change their current primary care physician because they might have a difficult time finding a replacement physician.

    My expenses continue to increase as my income declines. I am very frugal both in my office & personally. I have a minimal part time person to assist as needed. I do all the rest myself because I don't have the income to pay someone else. I did not finish paying off my medical school and practice start up loans until I was in my late 40's. I had to buy replacement medical equipment in 2009 and am paying off that loan through 2014. My car is a 2000 model. I have had to draw from my savings to pay either business or personal expenses for the past 3.5 years. I have not had a vacation in 4 years.

    I would really like to know where these "studies" obtain their numbers as to physicians' incomes. My physician friends in Texas, New York and other locales are having a difficult time paying the bills. A number have retired or gone into 2nd careers because medicine was not paying the bills. My overhead with office rent, insurance, medical and office supplies, mandatory Continuing Medical Education, membership & hospital fees is around 80%. If Medicare reimbursements are slashed, then I will be forced to leave medicine and enter my 2nd career at nearly 60 years of age.

    The vast majority of physicians care about their patients. But Medicine is also a business and income has to exceed expenses. The punitive requirements by the US Government concerning reductions in Medicare reimbursement if you cannot afford electronic records, or if you do not do electronic prescribing, coupled with the additional expense to be incurred with the transition from the Diagnostic Coding system ICD-9 to ICD-10 (and for what practical reason) will force many physicians out of practice. Most electronic medical record systems start at $100,000 per physician in the practice, or you can rent a system for $1600 per doctor per month. The transition to ICD-10 is estimated to cost tens of thousands of dollars per physician. In some European countries with EMR, the government provided the system at no cost to the physicians so that everyone would be on the same system. Here in the USA, there are multiple vendors promoting their system with no guarantee that it will integrate with another for the purpose of patient data transmission.

    Right when we need more physicians (there is already a shortage in Texas), physicians will be forced to leave medicine due to the costs of staying in business.

    I love working with my patients and feel great when I feel I have made a real difference in someone's health. Who will be there when it is my turn to be on the other side? My own internist had to change to concierge medicine to be able to stay in business.

    I do not know the answers to the issues, but doctor bashing is not it. We work hard and care about our patients. But not earning enough to pay one's frugal bills and dipping into money set aside for retirement is downright depressing.

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  25. I don't think nurses are vital. I think NURSING AIDS are vital these days. THEY need some credit for doing all the hard stuff!

    ReplyDelete
    Replies
    1. Come on - we all know that every member of the healthcare team is important, and this includes the NAs.
      Do yourself and your nursing co-workers a favor - work through your anger. Everyone around you (including your patients)will be better for it. Good luck.

      Delete
    2. Don't you mean you think that you deserve credit for what you personally do because you don't feel appreciated? This forum is so far removed from your experience and what you do, a hospital housekeeper who cleans up after the massive GI bleed that resulted in the code with the frenzy that followed while you stood frozen in the hall has more right to speak up here than you do. They have a more hazardous and demanding job by far.

      Delete
  26. Many of the above comments about NP training site "years of experience" prior to getting their NP... That is probably very true but it is not required and would be no different then my "years of experience" prior to going back to medical school. I worked as an occupational therapist for years before going back to school but even if you remove those years from my life my training to become an MD was 9 years long and my residency will be another 4 years of training. The author of the letter is simply saying the physicians sacrifice a great deal and when compared to other professionals whether they be nurses or pilots etc the compensation is not as favorable to the physician. All physicians feel that nurses are vital to patient care and provide expertise that we often don't but the reverse is also true. I do feel that my extensive training provides me with the ability to perform jobs that others can not. I am incredibly thankful for the nurses I work with who understood the effort I have put into my training and also understood that I did not know all of the answers my attending wanted my first July. It is those nurses that have helped me to become the physician I have always wanted to be and helped me to understand the complex roles nurses have with not only atient care

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  27. Great article! I am really tired of hearing that doctors make SO much money when in truth that is rarely the case. I am a pediatrician and we make even less than adult medicine because insurance companies believe that because our patients are small they take less effort... not true. I have invested 14 years of higher education, many many dollars and time.... and I have yet to make more than enough to pay my bills and put a little into savings. As far as nurses go, they are vital to what we as doctors can do. Yes, they work nights while we are "asleep in the call room" (rarely a true statement) but they also work 36-40 hours a week typically. This can't be compared to working 60-80 hours a week without relief. NP's are also vital but I agree completely that the training is significantly less and the knowledge about pathology is vastly different than what doctors have. This is just the facts. That doesn't mean that their role is any less important but it is difficult to see people putting them on the same level when it comes to training/knowledge.

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  28. While I do not disagree with the rebuttal; I have to point out that as a hospital administrator; I always hear MDs saying that they gave up their 20s as if its supposed to mean something. You know; you aren't the only ones who self-sacrifice but you seem to complain as if you do. I come in on the night shift, weekends, and carry a pager because I am on-call 24/7 to support my departments. I cannot tell you how many countless issues come up and my pager is going off every night because either a machine in sterile processing went down or staff call in sick and we need to find someone for a case. We do residency too and get paid the same; sacrifice for years, until we work our way up the ladder. I am just speaking for others within healthcare; what about all those sacrificing outside of healthcare? Are they entitled to the same pay later in their career for the hard work, sweat, and lost time with families or is it only physicians?

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    Replies
    1. How much money do you make?

      Delete
    2. At the end of the day in all these discussions, salaries are generally driven by market dynamics and supply and demand, not self worth or sweat. We all work hard and are underpaid. "How replaceable are you?" is the quintessential question for doctors, nurses, administrators, etc. For anyone. Takes me back to Sociology 101 in college in the 80's. Madonna makes millions not b/c she sings better than the back-up singer, but b/c the show doesn't exist without her. When the dust settles, who do you want wielding the scalpel, reading the scan, or deciding the drug interaction based on the thousands of hours of educational depth and decades of interdepartmental and personal experiences. Of course NPs blow away interns (who as recent med students have little practical training (only 2 yrs after 6 yrs of intense coursework), as an example, but on laps 4 through 500 its a different story. Adminstrators can cover a night better than most, but often have numerous people under them chomping at the bit if they get hit by a bus.

      We're on the same team at the end. But we have different roles wih different engines and different frames. And ultiamtely we all sacrifice.

      Delete
    3. Did your education requir you to go several hundred thousands of dollars in debt? Does your residency require the same hours as a medical resident (remember, they are only now talking about REDUCING hours to 80/week). Did you have to go through 4 years of college, then 4 years of post-grad education and then a minimum of a 3-year residency? When you are on call, do you have to stay in a call room at a hospital. If you are a little out of it and make a mistake in your orders at 3am, does someone risk losing their life?

      Are you really comparing your training and job to that of a physician?

      Delete
    4. I find it funny how you are trying to compare yourself to medical training. ROFL.
      Oh and trust me, you have no idea about sacrifice until you have done medical school and residency. Can you honestly tell everyone that you spent your entire 20's studying hours and hours, working 80-90 hours a week? I highly doubt it.

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    5. Leave your job as an administrator. You are not very good at it. The good administrator cherishes his/her physicians. Think about it. Who makes money for the hospital. The answer is doctors.

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    6. Actually when you run the profitability of some of our doctors they are not profitable because of their length of stay, clinical quality, or excessive product usage. The hospital would actually make more money if we let some of them go. Just saying.....hospital administrator.

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    7. I ask again, the original question. How much money do YOU make. It has not escaped my attention that you have not at least offered a ball park figure, contractual issues notwithstanding. You are indeed an administrator very good at saying a lot without saying anything. Also without answering the question.

      Delete
    8. Another point. Those docs who are not "profitable" what is their clinical success rate? Sometimes it costs more and takes more time to deliver the best care. So what is more important to the hospital, patient outcomes and satisfaction with their care, or profit. Seriously. I have worked in hospitals where the docs did what admin wanted, a mediocre job and guess what their outcomes were abysmal. People dying needlessly due to poor care, apathy, hurried diagnoses without proper assessments. I would like for you to put yourself in the shoes of the patient, or the parent of the patient who died due to a missed diagnosis that was treatable. Imagine it is your wife or child that gets cursory care. I worked in a hospital without an administrator, we did just fine thanks, with the med exec committee managing things. For serving on the committee, no additional pay,but time was carved out for meetings. Doctors provide care, but we can also deal with calling legal, ordering supplies, calling a boiler repair man and making sure babies are not abducted from the nursery or OB ward. I think it is your job that is of questionable necessity...in fact the hospital administrator at one of the most preeminent institutions in medicine in the WORLD is a neurosurgeon who squeezes his admin duties in between teaching, call, operating (brain surgery no less) and he gets minimal extra pay. With that said, it seems difficult for your existence to be justified, you don't make money for the hospital, docs do. So hospital administrators should be practicing physicians.

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  29. Someone needs to send a copy of this to President Obama and a copy to John Stewart and Bill Maher and Nancy Pelosi!

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    Replies
    1. I don't think any of them care about this issue at all.

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    2. In fact, all they care about is themselves and getting re-elected so they can continue to enjoy a life of privilege and continuous ego food at the gluttonous all you can eat buffet of special interest monies.

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  30. "I can tell you that my father who has worked on-call every year for the last 20years has put in more hours then a lot of doctors. The OB doctor at his hospital might reach my dad's hours but thats it. Even when he is not on call he can end up working 60-80 hours. Most of the time he gets no break during regular work hours and lunch is one bite on the go. I do believe most doctors do deserve to make more money then the rest (the exception being an anesthesiologist as most don't do crap and are paid on the backs of CRNA's. I will never let one touch me."

    I appreciate that you respect your father, but these statements are incorrect on so many levels. Only the OB at the hospital works more hours? Really?? What kind of hospital does he work at? Where are the neurosurgeons, vascular surgeons, cardiothoracic surgeons, orthopedic surgeons, pediatric surgeons, head and neck surgeons, general surgeons, transplant surgeons, urologists, etc at the hospital? As someone in surgical training, I see it on a daily basis. CRNA's are absolutely a big asset for the anesthesiologists, but their work mostly consists of putting in lines, intubating the patient, and sitting in a chair while the surgeons are on their feet operating; in this manner, one anesthesiologist can cover 5-6 rooms at once. And I don't know of any CRNA's who skip meals... they work in shifts; it's the surgeons who forgo meals in order to keep cases moving. Your comments disparaging anesthesiologists are incorrect and rather insulting. Let me ask you these questions: Who gets called when the patient is in cardiac arrest on the table? The anesthesiologist. Who gets called when the CRNA can't intubate the patient? The anesthesiologist. Who gets called when a line can't be placed? The anesthesiologist. And who is ultimately responsible for the safety of the patient both morally and legally? The anesthesiologist. I would absolutely want the anesthesiologist at the head of table when I'm the one being operated on, but hey, that's my opinion.

    ReplyDelete
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    1. "Your comments disparaging anesthesiologists are incorrect and rather insulting. Let me ask you these questions: Who gets called when the patient is in cardiac arrest on the table? The anesthesiologist. Who gets called when the CRNA can't intubate the patient? The anesthesiologist. Who gets called when a line can't be placed? The anesthesiologist. And who is ultimately responsible for the safety of the patient both morally and legally? The anesthesiologist. I would absolutely want the anesthesiologist at the head of table when I'm the one being operated on, but hey, that's my opinion."

      A surgeon (in training) standing up for Anesthesia... Me... right here... MIND BLOWN!!! Seriously though, as someone hoping to match into Anesthesiology after a year "off" to do research, THANK YOU for your astute observation. No matter what field, ultimately the legal responsibility falls on the physician. It's nice to see the appreciation.

      -Dr. FC

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    2. Thank you for that response! I enjoyed this article up until I read the comment : "I do believe most doctors do deserve to make more money then the rest (the exception being an anesthesiologist as most don't do crap and are paid on the backs of CRNA's. I will never let one touch me. The best thing a CRNA can do is find a hospital that doesn't have one) but their are many andvanced nurse practioners out there who are underpaid."

      Let me repeat this: "paid on the backs of CRNAs." Not only is that statement inaccurate, it also demonstrates that you have little to no knowledge about what exactly is the interaction between a CRNA and an anesthesiologist. Unless you are in that OR, with that patient, please do not comment based on what you have heard from family, friends, etc. I am a resident in anesthesiology and I just completed a 30-hour call on the L&D service, in which I had no CRNA to help me with lines, placements, new consults, etc. In fact, I worked almost completely solo. May I also comment that I will be repeating a second 30 hour call tomorrow. Again, almost entirely solo. How DARE you say that we make all our money on the back of CRNAs? Please do not offer an opinion unless you are informed on the situation. I have never been more embarrassed at a fellow person in healthcare than I was at you, at reading that statement. I am completely shocked and horrified at that comment. As an anesthesiology resident, I have, at multiple times, been as grateful to the CRNAs as I am to the nurses on the L&D floor as well as the nurses in the ICUs, regular floors, etc. I am thankful that there is someone else out there who can defend my profession, and eloquently state the multiple responsibilities we carry for the rest of our lives.

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    3. As an anesthesiology resident, I would like to thank my surgical colleague for his kind comments. I would also add that out of the overall group of physicians, it is well known that the surgeons are the ones who generally have the worst work hours, call schedules and vacation. This is because they are acutely aware of their direct impact on patients and take this responsibility quite seriously. As such, I thank them for their time and dedication.

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  31. finally someone who knows what they are talking about

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  32. Why do some RNs think they are equivalent to a physician? The education is different, the training is different and the roles in the hospital are different.

    If you are one who thinks this way, get the chip off your shoulder. Perhaps you should have gone to medical school... wait... let me guess... You could have gone to med school, but you rather be a nurse right???

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  33. Thank you for speaking up. It is time for people to have a reality check. The major causes of the increasing healthcare cost are increased aging population and chronicle conditions. Just look around it is not hard to see.
    In order to deal with the ever more serious problems, rather than cutting physicians' pay, we should do the exact opposite in order to attract more bright young talents. With most primary care doctors in short supply and underpaid today, overpayment is without any doubt, the last issue we should worry about.

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  34. Let's start comparing doctors hours and pay to that of a teacher. Not even close. That's where the salary increases should go!

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    Replies
    1. Really? I was unaware teachers hated on doctors too. Do you get vacations? Summers off holidays off. If so, reconsider your position.

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    2. Best not say anything like this in earshot of a doc or nurse. Instead of getting an oral antibiotic, you might need a painful injection instead, you know to kick start your healing process. It's not unethical, it's best practice. Where mercy might have been applied, it was instead removed from the docs willingness to be flexible. And don't forget the nurse can make the injection quick or slow, bigger gauge needle or smaller, lidocaine or no lidocaine. Think before you speak. Someday, you may regret disrespecting someone who needs to filet you open for emergency surgery.

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  35. Proud Nurse PractitionerAugust 2, 2012 at 9:15 PM

    Dear Dr. Valenti;

    Frankly, I am in awe of the breadth of your ignorance…. I will proudly start by saying I am a Nurse Practitioner. Creating such a response without doing your own research to the didactic and clinical requirements of the nursing profession. is, quite frankly, sloppy and irresponsible. I will not be redundant and quote these requirements as I can see that my fellow NP have but, I will add that we didn't get paid for our clinical requirements.
    Pediatrician Henry K. Silver and Loretta Ford NP, EdD, FAAN created our role 40 years ago. We have not faded out or become obsolete because we are a necessary part of the medical community. Hear me clear, Dr. Valenti, NPs don't want to be MDs….if we did, we would have chosen that career path.

    Your response can do nothing to better the medical community~ that is to say you clearly set aside your obligation to "do no harm."

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    Replies
    1. NPs dont want to be MDs?...thats funny. If you NPs didnt want to be MDs, then why become basically a less trained, less educated version of an MD, that tries to do an MD's work for cheaper pay?
      Why not justcontinue to be an RN? Your profession evolved as a way to curb costs and to fill the shortage of physicians. Your profession exists because of these reasons and probably moreso because of the unbelievable lobby back by the millions of dollars that are used to bribe our law makers. Unfortunately this cheapening of the medical profession with mid-level practioners is rampant. What do you think the purpose of NPs, PAs, CRNAs are? Lets just lay it on the table as it really is, without all the political correctness. You are cheaper labor.
      I am actually shock to see that you actually are arguing that RN/NP education is equivalent to a MD's education. Lets not forget RNs do not even need a bachelors degree. Lets not forget the anatomy/physiology/pharmacology/pathology and the rest of the didactic and clinic rotations you do pale in intensity and depth compared to MD education. I have seen many of my friends go to nursing school and the material i see them study is reminiscent of the pre-med courses I studied during unger-graduate school. Actually I take that back, my unger-grad studies were actually tougher and in more depth.

      Finally, please give up this crap about "do no harm." If you truly believed in this you should stop practicing yourself... and if not, then you would go to medical school and residency to get real training.

      Tired of being politically correct...

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    2. There is a growing movement for NPs to work with out a physician supervisor, this would be considered in most circles a want to practice medicine....

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    3. Dear Proud NP,

      The breadth of ignorance on this entire message board is astounding. To put things in better context for you, I am in my last year of residency. It took me 4 years of college, 4 years of medical school, and soon to be 3 years of residency training before I can practice alone. I admit that I am ignorant to the exact didactic and clinical requirements you had to meet to finish NP school, as you are clearly ignorant of the rigors of physician training.

      No one said NP's wanted to doctors. No one said you are or should be obsolete. In fact, EVERYONE has acknowledged how vital you are to the medical profession. However, you do not get to compare your training (which as my best friend has told me over the last 2 years is very difficult) to that of a physician.

      You can bemoan that the doctor didn't do his reasearch and that you didn't get paid while completing your clinical hours. First, the history, scope, and educational requirements of NP's had absolutely nothing to do with the focus of his response letter, nor did it really have much to do with the commentary that inspired said letter.

      Second, we didn't get paid for our 3rd and 4th year as medical students which are all clinical hours, during which we also take call. With my admittedly small amount of knowledge of NP education, this is what I learned from 3 nurses I work with and who completed NP school within my residency: 1) NP school took them 2 years total (yes they had their BSN, but we had our bachelors before going to med school). 2)THEY WORKED AS RN'S WHILE IN NP TRAINING. Practically full time. 3) They graduated, passed their boards, and are now able to work in various specialized fields that require physicians to complete extensive residency training. 4)They are wonderful and brilliant, and not one of them says "I could have been a doctor". In fact they like to tell me they chose smarter. However, not one of them would try to say that their training is equal to mine.

      So please drop the pseudo-philosophical rhetoric and tongue in cheek comments. His response to someone else's defamation of all health care workers can do nothing but better the medical community, even if by something so small as sparking dialogue and drawing attention to spending discrepancies in this country. (See his mention of the Mirena IUD). Please do your own research, read the commentary he was responding to and direct your vitrol at Lehrer.

      For my own tongue in cheek comment: Yes, by writing a response to a man who insulted all health care workers, he clearly failed in his obligation to do no harm. Apparently this is largely in part to the fact that he did not pay appropriate homage to nursing. Our obligation is to the patient, as is yours. Defending health care workers, which God forbid, includes physicians, and bettering the medical community are in no way mutally exclusive.

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    4. For nurses who wish to practice independently, here is the truth:
      A physician trains for 4 years of undergrad, 4 years of medical school, a year of internship, 2-6 years of residency (depending on the specialty) and 1-3 additional years of fellowship for subspecialtiy training. At each point along the way, there is a weeding out process and only the best and brightest advance to the next level. This occurs at the MCAT level when applying to med school. It occurs after year two of medical school when you take step I of the USMLE. It occurs at the end of 3rd year of medical school as you take step II of the USMLE. It occurs at the end of every clerkship as you take the national shelf exam for each specialty (medicine, surgery, psych, pedi, ob/gyn etc). It occurs at the end of medical school as you compete nationally for the best internships and residencies. Once in your intern year, you clear step III of the USMLE before you can get a license to practice. Each year of residency, you take the in training exam which helps determine if you get to advance to the next level of training. If you get past that, you apply to fellowships where only a small percentage are accepted to the most competitive spots. Once you finish residency, you get to take a written board exam, many of which are so difficult that the pass rate is in the 70 percent range. If you pass the written exam, you get to sit for the oral exam (one of the most stressful experiences any person can ever be subjected to). The pass rate is 70-80% for many oral exams. At the same time, many young doctors are enrolled in fellowships or paying their dues doing additional “chief” years so that they can be eligible for 1-3 year fellowships. All of this time, still being paid minimal salaries and working long hours. Once finished with fellowship, then they must sit for their subspecialty board exams. Once complete, it is now time for recertification in their primary board within the next couple of years. And so it continues. At any step along the way, the weak or unqualified are weeded out.

      Compare that to this:
      A person decides they want to be a nurse. They enroll and take science courses for non science majors for a couple of semesters. They do their clinical rotations following other nurses around and implementing physician orders. They graduate and get a job within 2-4 years of making the decision to be a nurse. They are in high demand because all of their nursing colleagues with any ambition are either nurse practitioners or clipboard carriers. They are paid well and work hard. They see additional opportunity and sign up for a DNP, CRNA, or NP program and 2-3 years later, they are done, all the while earning a great living as a nurse while doing the entire DNP or NP process through on line courses at their own convenience. They arrive at the end of training with no debt and no sweat equity and very little actual “medical knowledge.” At no point in the process was there a weeding out process to separate the qualified from the unqualified. Their entire time is spent following physician orders and not in formulating treatment plans or learning how to diagnose the difficult patients. It is assumed that if you make the decision to go to nursing school, you will be a nurse. If a person makes a decision to go to medical school, their is only a small chance that their dream will come to fruition because most get weeded out along the way and most don’t have the drive and stamina to complete the mission.
      Meanwhile, nurses join their nursing political action committee and lobby the politicians to claim equality.
      And for the record, yes, nurses do wish to be doctors. That is why they have created the online Doctor of Nursing Practice and are currently lobbying everywhere to call themselves "Doctor" in a clinical setting. It is misleading to patients.

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    5. Dear Leah- I love your response to Proud NP. Get rid of your BIG CHIP. NOW.

      Thanks,
      The female physician

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    6. I have no doubt you are an intelligent person but, spewing such negativity when your knowledge is limited? Not doing your research before such assertions is irresponsible.

      Yes I am an NP. No, I don't want your education, responsibility, or your job. Yes, I went to school for 4 years then 2 more for my Masters degree. It was NOT online….bricks and mortar right across the street from the medical school. My undergrad was 140,000.00 and my Masters was 56,000….200,000 education. When I interviewed, after graduating from one of the best school for NPs in the country, I was offered between 55,000 to 68,000. I have worked hard and negotiated hard to now make 91,000 that is more than most NPs I know who make closer to 70,000 BUT- we bill for 85% to your 100%……I do this because I LOVE being a NP - not a MD.

      DNP- There have been many doctoral programs long before the DNP- to include Doctorate of Nurse sciences and PhDs. I know this because every professor I had was a DNS, DNP, PhD and all in grad school had to also practice as a NP- as it was a requirement by my university. This is nothing new- its just a hot topic once it was called a DNP. A pediatrician (Silver) and Nurse with a PhD( Loretta Ford) created NP role in the early 70s.


      Hope you practice medicine a little more responsibly then you posted this response.

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    7. There is no need to state your education. It is redundant- we work in healthcare…we know- we hear your whining on a daily basis.

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    8. I have a friend who is an np who decided to get an MD. She did not graduate from med school. I have a friend by contrast who was an ICU RN, who went to med school and residency and she is one of the best doctors I know. What did you learn?

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    9. Reality sandwich is bitter, just like the nurses jealousy.

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    10. My point in stating that we do clinical without pay is in direct response to Dr. Valenti's comments about how little he made during residency. I really don't care that I didn't get paid- I do this because I love it. I loved taking care of my dolly's when I was a child, I love volunteering in high school at the local nursing home, I love being a nurse….but, I am smarter than most so I go to graduate school and become a nurse practitioner. I love being a NP….it is the best of all…we make a decent living, we have better hours, we have less responsibility~ what's not to like about that?

      I started looking at this piece to get his view on healthcare costs. I am relatively well travelled and thought this may be an interesting on a global level and a fair response….barely a few sentences in and he needs to slam the NP education, then pilots, then concludes that we are in doom and gloom in healthcare because NPs are less educated than MDs~ how does anyone expect us all to react??? I will defend my career calling to the end. MDs are the most educated with the hardest education…no one is arguing that. Your education doesn't degrade mine- its just different. Our is based on an extension of the nursing practice to a graduate level.

      Answer this- why do you have to toss NPs under the bus to make your point????

      Delete
    11. Look everyone….the point is this…

      ~ a quote from one of our patients when I asked if the his PCP or the NP in that office cancelled a particular medication " No, they didn't, they want me to take it. The insurance company discontinued it"

      NPs get a masters degree, MDs bust there butt in med school and residency. We all do our part to have an insurance company practice medicine for us.

      Delete
    12. Dear proud NP. You will never be as good as a doctor simply because you don't have the knowledge nor education. In fact I don't employ any mid levels in my practice. I would much rather hire MD or DO. Don't get me wrong. I do not have any idiosyncracies against mid levels. I just don't find them helpful. I would had they gone through the same training i have. The best NP i have ever seen, who had 7 years of experience, was as good as a second year resident. Mind you residency is at least 3 years. I am glad that you are proud being an NP, but you will never be a doctor unless you go through med school, residency and if desired for subspecialty , a fellowship.

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    13. If NPs and RNs were so good, why do they keep on waking me in the middle of the night for chest pain / shortness of breath / "not looking good"? Not to mention all those sleep med calls.

      Everyone has a role. No one is superior to another. I can't do what you do. Don't pretend you can do what I can.

      Delete
    14. To the female physician, thank you, happy to oblige. I hope you are not referring to me when mentioning the big chip?

      Delete
    15. "Your profession evolved as a way to curb costs and to fill the shortage of physicians. Your profession exists because of these reasons and probably moreso because of the unbelievable lobby back by the millions of dollars that are used to bribe our law makers. Unfortunately this cheapening of the medical profession with mid-level practioners is rampant. What do you think the purpose of NPs, PAs, CRNAs are? Lets just lay it on the table as it really is, without all the political correctness. You are cheaper labor."
      I COULD NOT HAVE SAID THIS BETTER MYSELF!"

      also tired of being PC!

      Delete
    16. Proud Nurse PractitionerAugust 4, 2012 at 1:07 PM

      Dear AnonymousAugust 3, 2012 8:41 PM

      "As good as a doctor??" I am a nurse practitioner and that is what I am very good at. I am not as "good as a doctor" because I am not one- and don't want to be one…and further more I measure myself against my mentoring NPs not physicians …how many times do you have to hear that?

      I know the MD I work with is so much more knowledgable that me….he did 2 residencies and a fellowship. He knows that and is very helpful to further my knowledge… and I help him see things from the warm and fuzzy nursing perspective. It doesn't take an MD to do a H&P, a f/u for med check, education,etc~ I can do all that so he can focus on more complex pts or procedures. That is how we work well….maybe that is not right for your practice and that's fine~ but it works well for us. I know what I don't know and that doesn't stop me from trying to learn something new everyday.

      I really do think MDs that think NPs want to be MDs really don't understand our role. You are all physicians so you have some desire to be at the top/ in charge. Perhaps you cant conceive that we are more knowledgable than a bedside nurse but don't want your job either but, honestly, we are more than comfortable being the bridge between the RN and MD.

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  36. No Mr nice guy here. I would rather open a pizza restaurant then give out too much free care, I would rather spend time with my wife, children, and family. I can find many other ways to make money, maybe start my own radio show attacking the media. This Dr is ready to adapt and attack back. I did not spend all these years in school etc 436k in loans to be takin advantage of.

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    1. Let me know if you need a sidekick, because on my deathbed I can assure you being a physician is not going to even cross my mind as one of my greatest joys or even accomplishments. I'm out.

      Delete
  37. I love the nurses and NP's attacking doctors and claiming equivalence and even superiority...I say good for them...as long as they don't pretend to be doctors and proudly explain their nursing backround to every patient they see they should see patients...independent of doctors...carry their own malpractice and be liable for any mistakes they make...let lawyers have at them...
    Any patients who think NP's are equal to a doc should see an independent NP...I'd love to watch the skyrocketing costs associated with NP's covering their asses with un necessary testing while Practicing independant of any overpaid idiot supervising physicians....
    Experience does not equal knowledge....extenders have a role...they are extenders....this new activism is soo stupid...keep lobbying for equality...the lawyers will have a field day....just out on your big nurse pants and get your own malpractice insurance...stop hiding behind physician supergiants or misleading patients into calling you " doctor"...correct them and say no I'm a nurse...you dont need a doctor...

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  38. Not to put down doctors, i wont put down anyone out there that is working hard for their dollar. I'll just put my view on this.. What the Dr. Valenti said is I'm sure very true doctors are not the ones to blame for high healthcare. Doctors for what they do should get paid well and sadly in this day and age 100,000 dollars isn't a lot of money when you sit down and think about it. However that being said i come from a lower class then one of a doctor and seeing things from the outside looking in. Doctors as some of the nurses have already pointed out are not the only underpaid and unrespected people out there. Sure they have all worked very hard to get where they are and so have a lot of others. Doctors are not the only ones putting in 60+ hours in a week a lot of other occupations do to with a lot less pay mind you. Once again I will not trash doctors they are for the majority very hard working people and really do care. But, this article seems like and a lot of the comments in favor of it seem slightly ignorant in the fact you aren't only hard working folks out there that maybe need a little more than a pat on the back. Hope none of you take this the wrong way because it was not meant to be offensive just mearly pointing out there are others too, Thank you Doctors and Nurses for all that you do!

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    1. The point of Dr. Valinti's letter was not to cry "woe is me" or "Doctors are the only ones who work hard for little pay." It was a rebuttal to an article that was basically stating that doctors make too much money.

      And as far as the other jobs out there...name another profession out there where you or your 'representative' (aka health insurance compay) can name the price for services rendered regardless of the cost for rendering those services.

      Try this: Take your car into a mechanic to be fixed. Once it has been repaired, try to drive away without paying. Better yet, drive away (drive like you stole it, because that's what the law will say happened), then tell them that you will not pay what they are charging...you'll only pay them much less. Tell them that you won't even pay enough money to cover the expenses for fixing your car. See what happens next. Will the courts rule in your favor or the mechanic's?

      Yet that is what is happenening to physicians on a daily basis.

      What would happen if physicians decided to strike...left all health care to those who didn't hold an MD or DO degree? How long would it take for the government, the public and others in health care industry to changes things? How many people would die in the process? Maybe that's why physicians "whine"...why they don't have much bargainging power...because in the process of becoming a physician, something is born inside that compells them to help another human being.

      If this isn't fixed, what will happen is there won't be anyone willing to go to medical school and the current physicians will slowly retire or turn to other jobs - one by one. All that will be left, will be the RNs, NPs, CNAs, etc to take care of the masses...health care will become a trade career. And my hats off to the nurse, but a huge piece of the health care puzzle will be missing and the general public will suffer the consequences. By then, it will be too late to fix the system.

      A comprehensive solution needs to be created...now.

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    2. Yes. And NOW. It's already begun, it worsens each day we chose apathy over action.

      Delete
    3. You said everything in the first three words. You did in fact, put down doctors. Did you know that many physicians, if you do the math money for hours worked, we're making less than minimum wage. In fact, I know a considerable number of docs who would rather work less and make less money, but the debt burden takes that option off the table. Right now, I would much rather work at Starbucks, have healthcare, no licensure expenses no recertification exams, no malpractice premiums, no fees for the DEA, fees for this that and the other thing. Then I might see my kids before they grow up or I die, whichever comes first.

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  39. Thanks for the well written article. Here's my two cents to add to it.

    Fact: I am working my first year as an attending in primary care. My husband is doing specialty training where he continues to earn a resident's (low) salary while still accumulating student loan interest. Taxes take away 30% of my gross salary each month (and by the way, I can't deduct the many thousands I pay yearly in student loan interest because I "make too much"), My student loan payments then take another 1/3 of my net salary after taxes, and will continue to do this for more than a decade to come. My husband and I are 31 and together have well over a HALF MILLION DOLLARS in student debt. So, no, I don't think I make too much...

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  40. Nice response. Few points:
    1. Number of hours by itself isnt a criteria for who is better etc. Even if it is 30 hours shift. Then NeuroSx resident becomes top of the list belittling every peds/psych resident etc. We are all important part of health system whether it is MD, NP, RN, CRNA, rad techs or even clerical staff. Dr. Valenti didnt even try to belittle the nurses and was just trying to make a point and cover everything the article said.
    2. whoever is giving example here about me or my dad or else worked more, are forgetting that you are talking about one isolated example. As a human being, we tend to forget how to generalize and whether to generalize our personal experiences.
    3. Medico-legal liability. Very few people talked about this. If something wrong happens, the physician is the one to blame in all instances. Please appreciate that. It isnt easy to deal with medico-legal issues while providing the best patient care. And we all try to do our best.
    4. We shouldnt try to belittle ourselves like above while ignoring the culprit are beurocrats, pharmaceutical companies and insurance companies.
    5. Call. As far as call goes, please dont belittle poor residents. It is huge responsibility and no way board certified physicians, NPs, CRNAs and RNs come even close to them.
    6. Responsibility: Majority of my RN friends say they are RN and not MD coz they dont wanna be in front seat of making decisions. Another reason is of course they cant afford it, which sucks about our system. Again, I respect those decisions. We just need to understand each others' role in patient care. It is patient at the end who matters and we all care about that. And thats whats cool thing about this profession.

    Focus guys. Focus.

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  41. How sad that the important message that Dr. Valenti was trying to convey gets misinterpreted as an attack on nurses, leading to some nurses writing overly sensitive posts that distract from the main point of the article. Now, instead of focusing on the important message of why health care costs are so high, the comments have focused on why nurses should get more respect. To the nurses who have whined and complained, IT'S NOT ALL ABOUT YOU. The main point of the article is that doctors are not to blame for high health care costs, and to better understand why health care costs so much. The point of the article was NOT to belittle or disrespect nurses. Shame on the nurses who have posted above for letting their EGO divert the discussion to "doctors against nurses", and distract from the more important discussion of why millions of Americans are dying because high health care costs. The major problem with our health care system is not nurses being disrespected. The major problem is the cost, and recognizing where that cost is really coming from. So, to the various nurses who have posted, FOCUS on what's important and STOP ASSUMING THAT EVERYTHING A DOCTOR WRITES IS AN ATTACK ON YOU.

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    1. I read both articles and they are both have quite negative undertones. Dr. Valenti's certainly has great point but, unfortunately he miss the mark when he chose to bring NPs and Pilots into the argument. I do think there is a lesson in all this-why are nurses/NPs sensitive to this comment by MDs? Is it the obvious hierarchy that exist in the medical community? They are not off base. I saw a whole topic on SDN that was bashing the NP boards. Some really seem to have a problem with NPs

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  42. From the same doc who put herself through school and then had to have neurosurgery and foreclosed on her house due to inability to work I feel compelled to state that I did so by working in many a minimum or low wage job. I know what it feels like to live on less than 8000 dollars a year. I lived at poverty level for a long time. I worked my way up and I busted my ass to do so. Also, I am so tired if nurses having a chip on their shoulder about the whole doctor nurse thing. We should be working together as a team not belittling each other. If you wanted to be a doctor you could have gone to med school too. Really, just get over yourselves already this article is not about you. When the time comes that an NP can perform brain surgery, let me know. Until then doctors got where they are by working their asses off and having a lot of native intellect and talent. I do love NPs, but that is not what we are discussing here. As for teachers, no comparison. Most of my friends are teachers. They did not train for a minimum of seven years beyond the 4 years of university to do what they do. Further, how often ones a teachers job involve life and death in 5 minutes types of situations. Do teachers carry malpractice insurance? Oh yes and I taught at the college level as a grad student so once again I speak from experience. Enough said.

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  43. Team. How did this turn in to a nurses vs doctors free for all? Point the rage where it belongs. Dr Valenti may have mishandled some of his statements but the essence of the piece applies to all of us in healthcare: that salaries are not THE driving force for high healthcare costs.

    I came to the USA to study public health at Harvard. We talked about healthcare costs alot, believe me. There are so many factors: High transactions costs in a fragmented insurance system, litigation, a dearth of genuine primary care all rounders (such as the FP or the NP), higher proportion of specialist care compared with other systems, inability of states to share drug price data, the publics desire for high-tech care, the MDs desire for high tech diagnostics..etc etc...ALL lead to high costs. Pointing the finger at healthcare worker's salaries is pointing it in the wrong direction.

    I'm an MD from Australia, where doctors and nurses get paid considerably more yet healthcare is about 2/3 of cost (as a proportion of GDP). In Australia my yearly healthcare insurance is $900 yet here it is $9000 and my colleagues earn less here than my colleagues in Australia. Go figure!

    NPs substitution in primary care is not THE solution (but it cares for an important segment of patients). Obamacare is not THE solution (but in my opinion is a big step in the right direction). Changing payment systems is not THE solution. There is no silver bullet. And we won't find the many solutions necessary if we're yelling at each other about work hours or pea-cocking about the merits of our respective training. Fight the good fight, together.

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    1. Whey the Heck did you leave Australia? Maybe I should expatriate there... My only issue is the staggering number of excessively and needlessly so venomous and toxic terrestrial and marine life that could ruin an otherwise great day...

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    2. Look, the reality is that medicine as we know it is going to die and be reborn. What will emerge from the ashes is anyone's guess. The middle class in America is dying and since the physician community used to comprise much of the middle class, we are becoming an endangered species. Let's, face it, our jobs mostly suck now, and even more so in primary care where people are being pushed through like cattle off to slaughter. Doctors are seen as a disposable resource and healthcare is the new "bubble" even though the roots of the bubble extend back into the early 1980s. The rich bought up healthcare and are attempting to extract as much capital from the system before it is left in ruin, an emply husk of a body drained of its blood like a vampire's midnight snack. These tactics and discussions distract from the real problem which are HMOs and insurance companies swooping in and making themselves and their shareholders a fortune at the expense of our nations critical infrastructure. The fact that doctors are so busy and have in general high moral standards compounds this problem because we won't put our feet down and fight these jerks Mano a Mano. Add to that the fact that healthcare is a significant portion of the GNP, and that legislation ties our hands with all sorts of unfunded mandates and that each doc now does work that used to be dome by 3 additional staff besides themselves...It is plainly obvious why we are here, how we came to be in this position, and why it is going to get so much worse before it gets better, IF the system ever recovers at all. I realize that this sounds fatalistic, and I apologize. Unfortunately I think this less sensationalism and more likely fact.

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  44. Show me a nurse who does not want to make a discussion about medical care into a battle of the angelic nurses versus demonic doctors and I will kiss their feet. Nurses have a chip on their shoulder the size of Texas and for whatever reason choose to monopolize any real conversation about physician salaries and responsibilities. Somehow, every conversation ends up degrading into a lion vs. hyena rant session and the nurses want it to be all about them, all the time. I have made my patients beds when it didn't get done by nursing, I have collected stool and urine samples while the nurses sat at the computer surfing the web for vacation deals in sometimes, yes, even porn (male nurses). After my c-section I signed out AMA under 48 hours Post-op after having to make my own bed and suffering in dreadful pain. I don't work at that hospital. I know that I was treated badly intentionally.

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  45. I'm a nurse...I've done 48 hour call shifts....I've been up all night with patients....an I've mentored hundreds of residents...I've chosen EVERY SINGLE MOMENT OF IT and would never change a thing. I don't complain of the debt I incurred which aw like a mortgage. I've chosen this an thank God I did.
    So far a I can see it--- it's appalling that medical device companies and Pharma is allowed a capitalism model of business and has lead the way in skyrocketing healthcare costs. Example: the CEO of a major company makes $28.6M annually plus a $33k/mo slush fund. Guess who pays for this? The gov't and insurance comp's.
    Let's not make this about doctors or nurses- imagine if we pooled collective wisdom and charged to change BIG BUSINESS in healthcare? Instead...nurses are misinformed about docs....and docs are misinformed about nurses. We work together every day. Get to know each other and get together.

    Oh yeah...there are patients...remember them?

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  46. I love how Dr. Valenti spells it out. But for him to say he had to work harder at getting his education than nurses or NP's is insulting. many people go through school working full time. he had a wife to stay home with the kids. Many nurses and NP's work full time, go to school full time, and raise kids by themselves as single parents. He needs to wake up and realize while yes he paid his dues and worked his butt off to get where he is, he needs to remember who is running his office today.

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    1. Yes Patrick. Millions are dying because they do not have access or can not afford healthcare. Obesity and heart disease run rampant. Health care professionals are overworked. But WORST of all is that NPs are being insulted by physicians making offhand comments. If only Dr. Valenti would "remember who is running his office today", all of our problems would be fixed!

      If you or any of the ridiculous NPs/nurses who have been posting on this page really cared about patients at all, you would focus on the main point of this article, which is why health care cost is so high. It is not the result of the salaries of doctors or nurses or NPs. It certainly is not the fault of Dr. Valenti's comments regarding NPs.

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  47. With $300,000 student loan a newly medical school graduate was advised not to go into primary care because he will not be able to pay off his huge loan with current PCP payment. During family medicine residency program we worked 80 hours per week. Every 3rd day we were on call in the hospital working 3 shifts, from 8 am to next day 5 pm, that is 33 hours without sleep. An article I read: "... 21 hrs without sleep is equivalent to having a blood alcohol content of 0.08 – legally drunk! ....." A sleep deprived physician is an impaired physician. I bet none of you want to be cared by a doctor who is sleep deprived due to over work. With the amount of time we put in and the amount of money we received it comes down to $10 per hour. My account is making $275 per hour. Where is my big fat check you think I got?

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  48. Thanks to each and everyone who has responded to Dr. Valenti's response to the uninformed commentary by Mr. Lehrer. Dr. Valenti was not only defending physicians BUT he was defending ALL health care professional wages. Mr. Lehrer claimed all health care professionals, even janitors, made too much money -- and that is why health care costs are so expensive. SEE MR. LEHRER'S COMMENTS BELOW:

    Wage disparities exist at all levels of the health care industry. Even nonmedical professionals like janitors tend to earn more in health care settings than those working elsewhere. An extensive report from the Brookings Institution sums up the evidence: “Health care pays higher-than-average wages regardless of workers’ skills and demographic characteristics.” Indeed, the report goes on, “expanding health care is likely to raise wages throughout a metropolitan area by putting upward pressure on wages throughout the metropolitan labor market,” even for jobs requiring no post-high-school training at all.

    There’s no way around it. Wages drive high medical costs much more than any other factor.

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    1. Ha...the thing about averages is that they are AVERAGES, thus some industries earn more some industries earn less. Some janitors in health care earn more and some earn less than in other industries. I'm not sure what his point is? Wages are higher generally for good reason. People forgo salary for prestige, people won't work in dangerous jobs unless compensated. Janitors who regularly have to clean up shit puke and (potentially contaminated) blood probably think they should get $30-$40 more working at a hospital than if they worked in a corporate office. The supply curve of labour in the healthcare janitor market is shifted up. So what's his point? This only means that if you lower the wages you wouldn't have enough janitors. Mr Lehrer is evidently someone with a self interest in keeping healthcare wages low.

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  49. Im 3-4yr med student, I GOVT should rid of all my loans so I can quit med school and go back to being a firefighter/paramedic making 90k..

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  50. Dr. Valentin is correct and we are headed for some big problems! The insurance companies are raking in the money, we are not attracting our beat and brightest to medicine partly because they know they will be loadedwithdebt and we will have a physician shortage. boomers are aging!
    I am. CRNA with 38 years experience while np's and CRNa's etc can and do much good in our healthcare system, we still need our doctors.

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    1. Wished OBAMACARE addressed the issue of increasing health care costs instead of socializing medicine. Medical care is going to get more expensive, less available with reduced reimbursements to physicians and hospitals, affecting quality of medical care and research. 10 years down the line, you would need to wait 3-4 years for a joint replacement unless you can pay from your pocket!

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  51. So now all the Drs here are holding the hand of the nurse upset about the comment. The Dr wasnt speaking of a nurse, why would a Dr compare a nurse to a Dr, there is over a decade of higher lvl education the Dr has to do with hrs a nurse has never dreamed of.. Dr valente was speaking of midlevel NP/PAs which are very helpful but yes less educated.. A community college educated nurse shouldnt even be here in this discussion, your pay has still increased over yrs...

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  53. Let me try this again. I love all the passion I'm reading here. One big issue that affects our health care workforce is the pitiful low payments you receive for taking care of Medicaid patients. Please take a minute and read the story posted yesterday on how Medicaid payment cuts are affecting access to care. Please read the story and post your comments.
    http://www.meandmydoctor.com/2012/08/struggles-continue-for-doctors-treating.html

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  54. As an MD who racked up $250,000 in loans, works 80+ hours in a hospital along with the countless other hours at home or in my office calling patients, charting, filling out disability forms - all unpaid hours, i might add - does it anger me to be accused of making too much money, when there are computer programmers, pool cleaners, business consults who make more than I do? Yes, definitely it does.

    I look at the $15 million an actor earns to make a movie, or the other multi-million dollars earned in sports and entertainment; imagine the good that money could do in feeding the hungry or curing the multitude of orphan diseases out there. Why not cut entertainment payouts and funnel that money towards healthcare? Does Kim Kardashian deserve the millions of dollars a year she makes?

    I have asked non-physician friends how much they think physicians earn, and the answer is usually in the neighborhood of $250,000-350,000. Now while many surgical specialties or the so-called "ROAD to success" specialties (Radiology, Ophthalmology, Anesthesiology, Dermatology) may make that amount, the vast majority of the medical front-line and non-procedural medical specialties (e.g. endocrinology, rheumatology, infectious disease) are making not much more than $100,000/year in major cities, maybe even less in academia.

    Many of us in the medical profession choose this career not to make money, but to take on a caregiving role in our society and, simply, to make sick people better. Yes, I knew I would incur this much debt, work this much hours, give up valuable years of my youth; I chose it anyway, and the majority of the time I do not regret this choice.

    Medicine has, however, become an often disrespected profession, and many patients treat me as if I am merely a servant to do their bidding. I endure verbal abuse, outlandish demands, and patient neuroses with a calm and civil demeanor, as there is no recourse or defense for a physician who argues or yells back at a patient. As a resident I absorbed frequent anger directed at me for no other reason than I was the only consistent face in the patient room. Medicine is not the golden profession it may have once been, and the suggestion that cutting physician salaries can fix healthcare costs is a testament to this.

    If people want to discuss rising healthcare costs, they need to look to the "frequent fliers", the patients who have no insurance or minimal insurance who use the emergency room as primary care, who rant and demand whole body imaging, every blood test imaginable, and more and more of your time because they will not be paying the medical bills in the end. There are those who demand free medication and yet do not take any of the medications they truly need, only to suck up taxpayer dollars with their uncontrolled diabetes complicated by neuropathy and infections, congestive heart failure - they see primary care physicians, specialists, and simply do not take their medications or put forth any effort to take care of themselves, and then wind up in the hospital every 2 weeks. Who pays for their twice-monthly hospital visits? Not them! Or those patients who come through the ER and get admitted once a month for "pain" and then demand their IV Dilaudid with IV Benadryl while yelling at the nurses for not coming with the meds fast enough.

    The onus has fallen on primary care physicians to quarterback these patients to keep them out of ERs and hospitals, but how do you expect PCPs to continue seeing these patients with barely any payment?

    Yes, we all chose this profession knowing the sacrifices we would make and knowing the financial payout would not be tremendous for most of us. Unfortunately, however, desire to do good and a caring nature alone do not unfortunately pay anyone's bills, doctor or not.

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  55. The difference between a nurse and a doctor is YOU do OUR orders. You do not have the responsibility or accountability of someone's life in your hands. Clinical experience is no substitute for evidence, scientific-based knowledge. We study for hours. EVERYDAY. We go through a gauntlet of testing and certification. And yet you are allowed to have an "off" day and doctors do not.

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  56. I love that Lehrer brings up our compensation in comparison to our education. http://www.forbes.com/lists/2011/12/ceo-compensation-11_Stephen-J-Hemsley_NBHE.html

    I bet Mr. Hemsley was able to payoff his 4 year tuition for the B.S. he earned.

    On top of that, talk about the absurdity of where compensation in the healthcare business lies--it's certainly NOT in the pockets of the doctors--esp. when one takes into consideration our training, debt, work hours, etc...

    If you suddenly hear an atomic boom, it's most likely Mr. Lehrer's head coming out of his rear after he reads Dr. Valenti's post.

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  57. I would like to say all of us in the medical field are under paid. And residents do get days off. I see it on the paper everyday or sign out board. But THEY deserve it!!! I love the residents, faculty, nurses, MA's and front staff that I work with. Respect should be given to ALL people no matter what your title. World would be a better place. These residents work hard and we page them all the time. Some get snappy but don't take it personally we all have bad days are might not feel well not to mention lack of sleep. They come into residency and on day one have to make life changing decisions. Kudoos to the nurses who are educators as well, hope you NEVER shrug your shoulders and not help because it is about helping people, patients, docs and co-workers alike and if you are that bitter about your job go work at McDonalds! Try your best to be kind with everyone and if you have a bad day apologize when you can. People turning the meaning of this article around. And I do not think the Dr. meant any disrespect to nurses. If you had a bad experience and some doc made you feel lowly than that is the person you should be upset with because he lacked personal kindness and respect. Nobody here should be placed in a category that docs are like this and nurses are like that. WE are individuals who ARE HUMAN! WE all make mistakes and have bad days. I would again like to thank all the residents, faculty and staff for helping me learn everyday... because my goal daily is to learn something new. Please stop bashing each other.

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  58. I'm an NP,and an RN with 20 years of experience and totally get what the author was trying (somewhat successfully) to communiacte. I'll admit that the comments about nurses and NPs did ruffle my feathers a bit at first. As a mid-level provider (gasp, the term "mid-level is blasphemy to many NPs, although not me) I am fully aware of the limitations in my education and training when compared to my MD partner. I am also very respectful of the hours and sacrifice MDs have made. I thnk the reason the nurse-related comments drew such negative response (exclusively by nurses) is because of an inherant infiority complex most of us have about our chosen profession, especially with respect to physicians. It's a knee-jerk response based on years of marginalization by many (but certainly not all) MDs we encounter. In contrast, I have also had doctors who were truly appreciative of the role of the nurse in the health care team. I also believe it was not the author's intent to marginalize nurses. To correct a few inacuracies in many of the posts" RN so NOT work under an MD's liability insurance, unless it's provided by a practice to nurses in their employ. We are expected to carry our own insurance, and are held legally liable for our own problematic practices, often to the exclusion of the associated MD. RNs can't order or give medications without an MD or NPs order, but the administration of the treatment is a shared liability between the provider and the nurse...not exclusive to the provider. We are licensed professionals with our own regulations that govern our practice. I would also add that, while an NP does not have the years of education and residency of an MD, they almost always have years of clinical experience before being accepted to their graduate programs (in my case 10 years), well beyond most residencies. This is not, of course, an equivelent to the training an MD has, but is, in terms of hours, more than equivalent to the sacrifices suffered by the average "baby" MD just out of residency, in my opinion. We may not work 36 hours straight, but we deal with vomit, sputum, feces, blood, violence from patients and beligerance from unruly physicians on a DAILY basis. In the hospital setting, the average MD spends 5-10 minutes a day on a given patient. The nurse spends 12 hours with the same given patient. I'm not saying we are equal, or that the author's point isn't very valid, but my intent is to explain the vitriol expressed by many of the nurses on this forum.

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    1. Thank you for this post. As a resident, and after reading through some of the biting commentary made by members of the nursing profession, I really appreciate what you had the courage to write. Thank you also for making clarifications regarding NP practice. The one thing I disagree with is considering your years of prior clinical experience combined with your education as equivalent to the sacrifices made by "baby" physicians who have just finished residency.

      Obviously having years of clinical nursing experience under your belt makes you a better NP and from what I had been made to understand, was a requirement to enter NP training. (I apologize for not knowing the exact number of clinical hours/years required). But working as a nurse does not equal the hours or sacrifices of medical school or residency.

      I'm not looking for accolades because I chose to go to medical school. We all know going in that we are giving up years, that it is going to be a lot of insanely hard work. No one chooses this path because they think it will be easy. That being said, the 4 years I spent in medical school made it impossible for me to have a full time job. I was barely able to work the desk in the library, and even then I was sitting there studying. I missed the births of every single one of my nephews, countless other important family events. I have yet to make it home for Thanksgiving.

      I am not trying to marginalize, but I just can't agree that a nurse working her full time job because its her career is the same as the hours/years/sacrifices we make in medical school and residency. I don't think that going to work every day racked up a $300,000 loan debt for you as medical school did for me. Not to mention that thanks to new laws, residents can no longer defer their loans and must start making payments during residency. Even with income based repayment (a supposed economical break), my monthly payments are $492, which is basically like paying a 2nd rent.

      Please also do not assume that nurses have the monopoly on bodily fluids, patient violence, or being reamed out by physicians. Maybe its because I am doing emergency medicine, but I have been sprayed with large quantities of vomit, feces, urine, blood, and pus. I bedpan patients, change linens. Performing fecal disimpaction is disgusting. Pelvic exams and abscesses (and sometimes a combination of the two) are no better. I have been attacked by patients, one of whom snuck up behind me and literally ripped out a fistful of my hair. In addition to my attendings, I get to deal with ever-pleasant consulting and admitting physicians over the phone who dole out their fair share of verbal abuse.

      And believe me, we appreciate to no end that we aren't the ones who have to spend 12 hours with the patient. Nurses have rescued me by "paging" me out of rooms many times. But while the nurse spends those 12 hours with a set amount of patients, the physician is running around the hospital seeing all of the patients on their list, putting in orders, interpreting results, making treatment plans, answering countless pages, accepting new admissions/consults, all while shouldering ultimate liability.

      Please do not misunderstand me and think that I am trying to play who works harder. Nursing and mid-level practioners (I didn't realize this term wasn't PC, but it is unfortunately the technical term used by most hospitals) are their own separate professions. Nursing is different from NP, and both of these are different from physicans. We have different responsibilities and scopes of practice, this does not mean we don't all work hard.

      I am not looking for a pat on the back or to further incense the nursing population on this comment board. I am just saying that the grueling physical and psychological beat down that is residency sets our training apart.

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  59. As we have gotten so horribly off track, and since I have been abused over the years during my career as a physician, resident, med student, so badly once in front of a patient that the patient was offended by the nurse. He asked me if she was allowed to treat me that way. Sadly, I had to say yes. Let me give you a little perspective. On a website/blog devoted to a number of subjects relating to IQ doctors rank #2 second only to mathematicians at the experimental math level. Consistently, regardless of the way in which it is measured physicians come out in the #2 spot, in some cases behing surgeons ( who are also physicians). LPNs, by contrast came out behind bank tellers at #65, RNs behind social workers dental hygienists, real estate agents at #35 and, not surprisingly above government officials who come in at #37. So RNs are smarter than the congressman who makes the laws rulling their (and our) lives. But it is telling that until recently the smartest went into medicine. Even college professors with PhDs are down at #5 below a couple of specialized science disciplines such as geology and meteorology. So, the fact is, the smallest subset of IQ in the country has what it takes to be doctors. So to once and for all say what most MDs and DOs are thinking but are too polite to say, we ARE smarter than you. That does not mean however that we can deliver quality patient care without our team approach. Doctors need nurses (believe me or we would never let you treat us the way you do). We need social workers, physical therapists and lawyers to keep it all flowing as the medical machine must, to save lives. Yes we also need admin, but not as it is now, and I will tear you to shreds another day, hospital admin your day is coming. We need you less than we need MDs who heal and practice.

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    1. Harsh, but truthful.

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  60. When the CEO of Blue Cross- Blue Shield nationally retired 3 or 4 years ago, his retirement "bonus" was $130,000,000. How many lab test and surgeries weren't done so he could earn this obscene amount of money???

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  61. Very well-said. I don't know any rich doctors anymore, and I have many physician friends. Thank you for your thoughtful remarks.

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  62. I agree w/ comments above that this discussion between RNs, NPs and MDs is totally off track. I think that maybe some people did not read the original article (which this article refutes).

    And I totally agree w/ this rebuttal that physician (and nurse and janitor) reimbursement IS NOT the reason for the high cost of health care. Here is an interesting article about the financial situation of a Tahoe hospital for any of you interested in the actual point of this rebuttal. We should really be examining how much money is siphoned off into admin costs. And for a fun fyi: as far as careers go, becoming a physician is the slowest return on your investment...the fastest? Becoming an auctioneer! (Who would've guessed!)

    http://www.moonshineink.com/sections/spot-news/tahoe-forest-hospital-under-microscope-where-does-money-go

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  63. I love reading your comments. Would any of you consider writing a blog post I can use right here on MeAndMyDoctor??? You all have personal and compelling stories to share. And, your stories are important to get out to the media, our legislators and patients. They need to understand what you are up against. You can submit your blog post by going to the Contact Us tab.

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  64. Thank you. Ever other year, someone writes an article about doctors being overpaid. I don't think the general population has any idea what we endure to get the level of training we need to care for their loved ones. Even people in healthcare sometimes have no concept of all the work we had to go through to get to the hospital. Yes we make more than the average joe, but if you break down the hours we work for the salary we are paid, it nothing. That's not even taking into account the school loans we have. I've had nurses ask, is it hard to get into medical school. Thank you for defending our profession, but really, the public wants to believe what it believes. They want to make us the scapegoat for everything, and isn't that always the case.

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  65. genius...excellent, well written doc. Like the great Rodney Dangerfield would have said: I don't get no respect....

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  66. I do not understand where Mr. Lehrer is getting his information. As a physician, when I read an article like Mr. Lehrer, I am expecting more references rather than random facts without knowledge of where these facts come from. He is the "president of a think tank", he should know better.

    He writes "chartered actuaries — who calculate risk for insurance companies and must pass complex exams longer and arguably more difficult than the medical boards". Now I can't speak for the chartered actuaries exam but has he taken a medical board exam? Based on his bio, he appears to have experience in insurance analysis, wonder if he's biased on the difficulty of the exams. He is comparing apples to oranges as both exams are on completely different subjects,requiring different education. I would ask him to take our medical exams, including the USMLE I, USMLE II, USMLE III, Jurisprudence exam, and Medical Board exam (I would also ask him to pay for all these exams on a student and resident budget).

    Next, he writes "By some measures, American health care practitioners don’t work as hard as their peers in other countries." What is he talking about? No references to data, just generalization. He mentions the staff to bed ratio differences, which does not equate to how hard a practitioner works. Staff to bed ratio does not tell you how many patients overall the staff is carrying. I could be seeing 30 patients per day with a staff to bed ratio of 5 compared to another who sees 15 patient per day with ratio of 3.

    I would mention only a few more as I could keep going on with the ridiculousness of his statements.

    He states "an average year in medical school costs about $25,000 at most public schools; doctors make, on average, $80,000 more than lawyers but spend only one year more in school. And while many students capable of doing the work can’t find an accredited medical school willing to admit them". What? Where is he finding medical school with annual average tuition of $25,000. By average, that would imply a significant number of schools. I have yet to know any graduating doctors with less than or equal to $100,000 in student loans. Many have undergrad loans in addition.

    I am also sure that he as a patient would want a good doctor, would he be okay with medical schools lowering their acceptance criteria because he opines that "many students capable of doing the work" can't get admitted? There are other reasons why medical school dismisses applicants, e.g. grades and scores. Would you want a doctor who can "do the work" but gets D's in class?

    He mentions that medical school only takes four years compared to 3 years law school, and we supposedly make a higher salary (data?). As Dr. Valenti stated, medical education does not stop with medical school. It includes 3-5 years of residency and at least 2-4 years of fellowship if you decide to go into a specialty (e.g. cardiology), before you even start earning a "doctor's salary". Therefore the additional time that we are training on a resident salary ($11/hr before taxes currently) we are not earning a "doctor's salary", whereas the lawyers can start earning after law school.

    Last he mentions, "The overwhelming majority of health care professionals don’t need malpractice insurance". It took me a moment to get over this shocking comment. Is he living in the U.S.A., where lawsuits are in abundance? What doctor does not need malpractice insurance? I have known doctors who's practice suffered due to rising cost of malpractice insurance. And guess who's making more money from that, hmmm..., the lawyers.

    I do find it frustrating when non-healthcare people, make broad comments without true understanding of the profession, as if they are experts.

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  67. Everybody, PLEASE STOP the infighting. This is exactly why health care providers get dumped on. Every other interested party (hospital groups, lawyers, insurance carriers) have a unified voice and it's "divide and conquer" against the health care providers.

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  68. Well said, Dr. Valenti. This notion that people are ENTITLED (deserve, it's their right, etc.) to the hard work, years of study and sacrifice, and labor of another is absurd!! If i walked into anyone's store, resteraunt, or business and demanded items\services for free because "i had a right to it" i would be laughed at and mocked. If i tried to take items or services, i would be arrested or shot. But because the item\service in question is "healthcare", suddenly all ethics, laws\rules, and basic economics go out the window. The argument is made that healthcare is a basic human right,neccessaity, needed for a decent life, etc. Ok, on that premise... what about food? People need food to live, right? So why don't we all have a right to food whenever we want it? What if people walk into resteraunts, order food, eat, and then dont pay because "they have a right to it"? What if i walk onto your farm, or into your house and raid your fridge? You would be ok with that, right? You should be, since i have a right to food since i need it.
    What about clothing and shelter? I need those also, so perhaps i will start walking into stores and taking the clothes i want. Perhaps the people who get "free healthcare" should be followed home by the doctors who provided it and those doctors should walk right into the person's home and move into their bedroom. Why not? The doctor needs shelter, and he has a right to it.
    But it's your house, you say? Those are your clothes that people are taking, that is your resteraunt that people are eating at and not paying, that is your car that someone took? Well, whats wrong sweetheart, do you hate the poor? Those people have a right to foood and shelter, just like healthcare, right?? You had no problem taking services from the doctor claiming you had a right to his knowledge, labor, and service because you wanted\needed it. Well, someone else wants\needs your home to live in, your food to eat, the product of your work for themself, etc.
    Do you people see how absurd this is? It is completely illogical. However, society has developed this entitlement mentality (largely due to goveernment teaching people that they DESERVE things) that has citizens convinced that it isn't really STEALING if you vote to have the government take things from others against their will and give them to you. You didnt steal it right? It was just stolen for you, by politicians, so it isnt really theft.

    I am sickened by many of my fellow Americans who spit in the face of the morals and values that this great nation was founded upon. You dont deserve to be called Americans, and should pick up and move to the communist\socialist hell-hole of your choosing ASAP.

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  69. Excellent!!! And here is a study that shows that Dr Valenti is right: http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=783848&cid=PRAC

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  70. I find this very interesting that one of the complaints is that nurses don't work 36 hours straight.... Guess what. They don't work 36 hours straight because it isn't safe... I agree that MD are probably under paid especially pcp.. But this is your field. Change it.. Why do many of the proceduralists make so much money and the pcp make nothing? Again, relates to training, time spent learning the craft. This is your profession change it...

    Wen I had a surgery the first question I asked was how long have you been up, and how many cases have you done.. Time spent on ones feet working 36 hours really isn't anything to be proud off

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  71. To all of the doctors bad mouthing nurses with doctorates. My training is just as rigorous as yours. I worked hard at nursing school and had 10 years of experience working as a floor nurse. I then went back and got my masters degree and did that all while I was still able to work full time and raise a family. I am in my last semester of my Doctor of Nursing Practice degree. Am I going to call myself "Doctor" when I get out? You're darn right I am. I have earned it. I am doctorally prepared! No one has any right to deny me the right to be called doctor. Patients are smart enough to know the difference, so I don't have to explain it.
    I am tired of whiny doctors acting like they have more training. I had 4 years of nursing school and then another year for my masters plus 10 years of nursing experience plus my DNP degree which was another 1.5 years. That is almost 20 years of training. Medical school is only 4 years long to get a "doctorate." Mine took almost 20 years!!
    Also, nurses make better doctors because they care for the whole patient. Physicians barely spend any time with patients.

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    1. Lets put it this way, when a patient comes to the ED clutching his chest, diaphoretic, he is not looking for help from a DNP! Futhermore, Nurses dont "care for the whole patient," by doing what a doctor tells them to do, Not a DNP! so go ahead, have fun with that title, if it makes you feel better.
      Written by an MD

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    2. You're kidding me, right?! My 3rd year medical students have better training than a DNP does. Hah!

      You got what, maybe 1000 hours of training to practice as an NP/DNP? My 3rd year med students get nearly 5000 during just 3rd year. Not only that, they actually spent 2 years learning the hard science behind the practice of medicine instead of taking joke classes like "nursing theory" (lol). What a joke the DNP is! It's an insult to every other doctoral program out there. Yea, you got a "doctoral" degree...don't expect anyone to respect it when you got it online while working full-time.

      Your education is absolutely not rigorous. If we had med students take the ENTIRE NP/DNP curriculum, I would estimate that they would finish the whole thing in a matter of months. That's how easy it is. Btw, we have several NPs in our class who decide to pursue medicine. Every single one of them was absolutely SHOCKED about how little they actually learned during nursing school. Now, they're some of the biggest opponents to NP/DNP independence out of any of my colleagues -- because they know first-hand how little NPs/DNPs know and how dangerous they are to patients.

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    3. Well, let's see. Your 4 years of nursing school equate to 4 years of medical school if only by duration. Residency is a minimum of 3 years, but let's say that your DNP is equal to that (again, only talking about duration). Your experience counts about as much as a doctor's experience, so leave that out of the equation. How do you figure that you have 20 years of training compared to 4 years of training for a doctor? You've got to be kidding me.

      Moreover, the simple fact that you were able to work a full-time job while going to school should tell you right there what an easy program that was. Try doing that while going to medical school.

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    4. "Medical school is only 4 years to get a 'doctorate' degree." If I, as a physician, dared to make such a disparaging remark about nursing, NP, or DNP, you would be first in line to rip me apart. Do you seriously view your DNP as equivalent to an MD? Please explain to me why it is perfectly okay for you to be so bitingly disrepectful.

      A PhD is an honor, one you no doubt put a great deal of time and money into. However, you say your DNP took an additional 1.5 years after your masters, which took you 1 year as well. You don't get to factor 10 years of working at your job into your training and try to make that out to be superior to residency training. I don't add my 5 years as an EMT/PCT to my training, though it was definitely an asset. Your doctorate degree (and please note I didn't include your insulting quotation marks) took you 2.5 years, and you worked full time while achieving this.

      The science PhD's I know take at least 4 years to get their doctorate. They are paid a pittance stipend while working towards this, and none of them have time for outside jobs. During residency when you are limited to an 80 hr work week, and you frequently have to underreport your hours, no one has time to work another job, not even the ones with families!

      The rigors of DNP are not the same as that of a residency trained physician. Being a DNP, wearing a long white coat, and calling yourself doctor absolutely confuses patients. They will not realize you are a PhD, not a clinical physician. They will not understand that you are not their doctor when you come in the room. They will just hear the word doctor come out of your mouth and stop there. There is a sacred trust between physicians and patients, and by putting yourself out there as doctor to your patients you are violating it.

      Do college professors who are PhD's refer to themselves as doctors in the company of physicians? Do lawyers, whose degree is juris doctor, ever call themselves doctors? My uncle, who has a PhD in education, would never expect to be called doctor in a clinical environment. Because he knows its inappropriate and doesn't apply in that setting. Outside of a patient-based setting, you should absolutely be called doctor, especially if you plan on teaching.

      Again I'd like to emphasize the ridiculous disparity here in respect and tone. By putting your quotation marks around "doctorate" when referring to the degree I earned in "only 4 years" (because clearly that's where my training stopped and it was so easy), you are not only being nauseatingly condescending, but you seem to be implying that my degree/license is nominal at best. I would never question your intelligence, would never disrespect you or anyone in the nursing profession, the way you have just dismissed physicians.

      Apparently we physicians are all whiny and irrelevant, something you scrape off the bottom of your shoe. Please get the chip off your shoulder. If you have to demand respect in this manner, than you do not deserve it, you haven't earned it. You are doing nothing for your NP/DNP colleagues by representing them as petty, condescending, embittered, arrogant, ignorant, and dangerous. The NP's I work with would wipe the floor with you.

      -The whiny "doctor" who doesn't spend any time with her patients

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    5. As I said a friend of mine with an NP dropped out of med school she did not want to put herself through the intense training, and frankly did not have the needed intellect or background education to handle the demands of the rigorous academic institution she had been accepted to. Whereas a very smart ICU nurse who had worked on a reservation where she had to hit the books to keep her patients alive went to med school with teenage children mind you, then did an internal medicine residency and is now a brilliant hospital DO. Here's the thing. The nurses did not feel any less antagonism toward her. In fact she could do their job better than they could and practice medicine better than most of the docs. So if you are a nurse and want to be a doctor instead you can go to med school and residency. You can be an MD IF you have what it takes. With that in mind, there really is no reason for NPs to exist except to provide cheap labor, and remember you get what you pay for....

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  72. This is what happens in a Capitalistic society, big business is always the winner! Which is ironic because I would say most physicians are Republicans which support the big business/free market economy standard. Just like the physician stated in the opening, comparing US to Germany (socialized medicine). If you ever lived in another country you would see that the pay, patient population per physician, and quality of life are all better. The only way as a physician in the US that you are not at the mercy of big business is if you're running a cash only operation...and how many physicians are doing that?

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  73. Don't be confused between "everybody is entitled to healthcare" and "everybody should get it for free". Nobody is arguing the latter. People who say "everybody is entitled" are asking simply that the costs be deducted from your paycheck, as it already is for Medicare and Social Security. This gives you not only the benefit of healthcare when you're working, but also when you can't work. Being sick is painful; nobody does it on purpose, and it rarely occurs when we're prepared for it.

    Health care should not be rationed by a capitalistic system. That's great for things we can do without. If you have less money, you may rent or buy a smaller home, or make do without a car. But you can't make do without your health. Anything less than the best, most dedicated care, is unacceptable when a loved one is sick. Therefore, everybody should pay in, and everybody should get quality care regardless of their ability to pay *at the moment of care*.

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  74. Wow, this is sad, had the thread got hijacked. The insurance companies probably get a real kick out of comments such as these while they achieve record profitability, cut payments to physicians, and drop newly diagnosed cancer patients from their health plans. Forget about trying to divide and conquer, its already been done with these insults back and forth. To all nurse and physicians: we are not each other enemies. I don't know any successful physicians who will not acknowledge the hard work, dedication, and vital role of nurses and midlevels. I think most nurses appreciate that physician had a long road before becoming a fully fledged attending, and on average worked harder to get there (even though both groups worked hard). Lets focus on the problem at hand with healthcare costs: private insurers, big pharma. Lets not write prescriptions for new, expensive drugs unless a generic clearly does not fit the bill. I was proud when a pharm rep recently told me that of local physicians, I write a very low ratio of brand vs generics compared to average physician. Let's get behind Obamacare attempt to regulate the profitability of insurance companies, which are behemoths that are dictating how we practice medicine. Let's oppose Obamacare when it creates too much bureaucracy & regulations for physicians. Let's pay all healthcare workers fairly, doctors AND nurses deserve better pay. Other workers such as home health aides deserve health benefits. I've always thought this an ironic crime, that many home health aides cannot get health insurance considering the nature of their work.

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