19 December 2007

Can I get an AMEN?

Med Schools Fail at the Business of Medicine

Dr Wes said it! Can I get an AMEN?

I've blogged on this point before, and I will again. I couldn't agree more. What other vocational school leaves its graduates completely ignorant of the economic underpinnings of the industry they are training to enter?

Sing it, brother!


Arrgh. Even the usually sensible Graham doesn't get it. He seems to endorse the notion that:

The point of med school ... is to give you a foundation of knowledge to learn how to practice medicine, get exposed to all the medical specialties, and prepare you for internship. It’s residency that should be teaching doctors about how to be an attending.
Med school is about more than preparing you for internship. There's 30+ years of practice to follow, and you need to be prepared for that, also. It's not too hard to teach students some universal concepts about the business of medicine. A few lectures on contract law, some talks on professional negligence, maybe a bit on professional liability insurance, the difference between ICD-9 and CPT coding, a primer on various forms of reimbursement and how it is determined, the concept of Accounts Receivable, and some info on the RVRBS and how it relates to reimbursement. You hardly need an MBA. It could be done in a few weeks with half an hour three times a week, and could be crafted such that it would be applicable to students going into any specialty.

Don't kid yourself that residencies could or should do this. Residents are scattered all over the hospital working, and the lecture time in residency is a tiny fraction of that available in med school, and proportionately more precious. It would be better than nothing, and IMO, more advanced, specialty-specific talks on your future career should be a component of residency education. But as it is both residencies and med schools are abject failures in preparing future doctors for the realities of the medical economy. The result is that young doctors get exploited, and that doctors in general are crappy businessmen, and crappy advocates for health care reform. And that's an ongoing tragedy for the medical profession.


  1. I'm not a doctor but I definitely agree that there should be some level of business/economic training for doctors. Aside from helping them become competent at business management, a nice ancillary benefit would be that we might have some doctors running around with a deeper understanding of the causes of modern healthcare problems. As it stands now, many of the doctors I know seem to take a side of whatever political party they happen to be affiliated with, regardless of whether they can explain their support.

  2. "What other vocational school leaves its graduates completely ignorant of the economic underpinnings of the industry they are training to enter?"

    That would be law school, which graduates students with only the vaguest understanding of how a law partnership works (the corporate structure of most firms) or of how their hours are recorded, reviewed, and billed out. I had to go explain to an associate that he couldn't write down half an hour as "looking for stapler" as billable time.

  3. Elizabeth -- Thanks for making me laugh out loud. Our executive director once chided me on my admin timesheet for billing for two hours with the subject line of "Don't remember."

    I am actually surprised that lawyers don't get more business education. I kind of assumed they did. At least they know to read the f*ing contracts their future employers offer them. More than once I've offered someone a job and had to stop them from signing the contract I put in front of them, with the caveat, "read it first."

  4. I'm a second year med student and this issue has been bothering me more and more. My school does zilch in terms of education on these issues (in keeping with other schools I guess).

    I am considering starting a student interest group on my campus about it but not sure what resources to use. I know a ton of people who would join, but how can we teach ourselves? We don't know anything about these issues. Any suggestions? And don't tell me to find a faculty mentor from our school; when I've told admins and other docs around about it, they seem kind of horrified. Do people in academic medicine think docs should just be martyrs/slaves for the government, thankful for their pay no matter what it is?! The reaction I've gotten seems to be "Why do you want to learn about that? Doctors make plenty of money as it is!" ... feh.

  5. Most community colleges offer courses in medical billing and coding. I'm sure the per hour tuition is much lower than what you'd pay if it were a med school course, and you'd have someone who actually does it for a living teaching you.

    Myself I'd prefer a physician who'd spent his time perfecting his medical skills. If they want to be businessmen then let them get out of seeing patients and sell something.

    Lawyers often have more business-oriented backgrounds. I believe billing just comes naturally to them.

  6. anon 7:18...doctors are businessmen and -women just as much as any other professionals. They do not work for free. There are some factors that make their line of business different from other areas of business, but don't make the mistake that doctors are not businesspeople.

  7. SF, can you recommend any med/business resources?

  8. as you bring in the tragically unprepared new hires, are you giving them classes to bring them up to speed? usually orientation to a new job and possibly multiple hospitals is overwhelming. learning to practice is hard-you see different types of patients, treat things differently, don't know who to call for help. Additionally, you don't have as many people around and have to make tougher decisions by yourself faster than ever. if the recent graduates don't spend the time to acquire the knowledge on their own after a year of work, is it because they are busy learning other stuff more important to their longterm clinical success? i think most nwely minted physicians would think of themselves as failures if they didn't develop sharp clinical skills even if they had mastered the art of billing and coding and liability mitigation.

    of all the new graduates i have seen, i am much more worried about their clinical skills than their business acumen. i see people coming out of great programs who are not ready to practice at all. i can't believe the letters of recommendation i receive on their behalf. i have literally gone back and reread them because the difference between what i saw and what i read was so large. when i call back, i find some of these glowing recommendations are based on as little as 10 hours of exposure to the trainee. i strongly hope the training programs and medical schools focus on making sure their graduates are ready to practice medicine. the business end i can work with them when they join the practice. if i can't trust them to see patients independently, i fear for all of us.

    respectfully, i just don't believe a couple of classes during medical school will make them anything more than slightly familiar with terminology. they do not have the background to appreciate a lot of the subtleties. frankly, i think if you were to survey a lot of practicing physicians with many years of experience, they would not pass a very basic test about coding and billing.


  9. I'm a med student at Johns Hopkins, preparing to graduate this coming May.

    My thoughts are that mandatory business classes in med school are inappropriate. They already shove so much stuff down our throat that adding more non-medical stuff is a waste of time.

    If med students want to learn about the business of medicine, then it should be only on an elective basis. Let them take classes at the local community college, or at the college of business affiliated with the university thats attached to the med school.

    Making it mandatory in med school would give med schools yet another reason to charge outrageous tuition fees and overload us with even more information thats not directly related to medicine.

    Besides, when we arent learning about pharmacology, we are forced into these BS social engineering classes such as "patient and society" which are little more than liberal indoctrination programs into the "good" of socialized medicine.

    Dont get me wrong. I'm all for medical schools offering business classes on an elective basis. But it should NOT be mandatory.

    We're already 150k in debt, dont give the med schools a reason to increase that figure.

  10. Thanks for the responses,

    Trismus & Zelda -- I will give it some thought and get back to you.

    Anon 7:18 -- I think the medical billing & coding courses might be more detail than the average doc (let alone med student) needs. Docs don't need to be certified coders. They do need to know how the system works, and some more big-picture stuff.

    Anon 8:42 -- You are right on all fronts. We do orientation and monthly education (when we can) on the business issues. Most of our practicing docs are barely competent on the business side. On the other hand, they're mostly not administrators, so that's OK. and yeah, then new grads do take a while to come up to speed, but I have found the quality of education for most is otherwise good.

  11. Anon 2:27 -- I too spent some time under the dome and sadly found that attitudes like yours are very prevalent there. Academics, more than many others, tend to deride the value of filthy money matters. But they are wrong.

    Truth is, you are forced to learn lots of irrelevant stuff in med school. If you are going into Derm, you still have to learn about cardiology, etc. And everybody needs to learn the freakin' useless Krebs cycle. But unless you are going into research-only practice, the money is going to matter -- it will determine much of your departmental budget, how many doctors you can hire, how many residents you can staff, whether you can get research fellows, whether you can expand or renovate your ER. Even in academics.

    What's more, if you don't know how to read a contract, how will you know whether you are getting fucked when you are offered an employment contract? How will you know when your employer is skimming the cream of the revenue you generate?

    And all this is less of an issue in academic medicine, but remember that even from Hopkins, most folks still go into community practices.

    It's nice to be naive and idealistic while you can, but willful ignorance is dangerous.

  12. The JHU anonymous comment is unfortunately too typical. Most medical students are totally unaware of basic economics, and worse, are totally dismissive of basic economic facts - that someone has to pay them when they start practicing.

    I'd be willing to wager that most students will parrot some tripe about "The Government" having to pay them, "For The Public Good". Nice idea, but the concept that the government doesn't actually have anything to pay them with without first taking it (through taxes) from the people is more difficult to comprehend than the TCA cycle.

  13. I commented previously (and accidently) as trismus1. Any thoughts on resources? How did you come by the business acumen that you have today.


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