Why No Doctors in Them Thar Hills?

‘Cause there ain’t no money for ’em…that’s why.

By ‘hills’ I’m implying rural America, and unfortunately, most people living there pay for doctors through medicare.  As I’m sure you’ve heard, this lovely Guv program pays less than cost in many circumstances, which is a great primer for how to go bankrupt, but isn’t a good way to keep doctors around.

In general, there are many doctors who would gladly forgo the demand for actual dollars as compensation for their years of training and constant hard work.  American history is full of examples of small-town country docs accepting cremed marmelade and a basket of Emu eggs as payment for little Dirk’s delivery and circumcision.  Those days are disappearing, of course.  The reason for it is actually quite simple:  Medical training today costs close to 8 yearly incomes of an average middle-class American family.  In rural areas, where most families are hovering at the poverty line, training a doctor would cost roughly (emphasis on rough) the entire yearly salary of 3 low-income rural families for 8 solid years.

Few can afford this, of course.  Especially altruistic types, who tend to be broke in the first place.  So would-be doctors these days go into debt for the money.

And then the banks come callin’…and they aren’t happy with 3 chickens and a haircut every month for the next 40 years.  They want cash.  Bear in mind that Uncle Ebeneezer will at no time recognize concepts like “quaint Americana” or the notion of “civic duty”.  Civic duty to your average banker consists of leaving only one desk light on at night…the one illuminating the stunning windfall of interest payments soon to be arriving from the hapless big-hearted doc in Flish, SD.

“But!”  Our wise Guv exclaims, “Let’s institute loan repayment program! We’ll make it available to doctors who are willing to work in areas we will designate as ‘under-served’.  We’ll offer HUGE sums of loan-repayment money.  Something like $20,000!  Who can resist that?”

Great idea.  Except that every great idea from government has to be governmented, which then quickly turns it into a really stupid idea.  Governmenting.  It’s my new invention.  I’ve transmorgified a noun into a verb.  Since it’s my invention, I get to define it: 

Governmenting, v. – The act of taking a perfectly reasonable idea that could benefit vast swaths of Americans, endorsing it, and then subjecting it to a kaleidescopic array of regulations, bizarre armchair ethics, vague definitions and hyper-polysyllabic word definitions such that the initial idea is not only forgotten but dwindles into laughable obsolescence.

Yes, the Guv offers an average of $20,000 per year of loan repayment.  Sounds fantastic, right?  Except that the average doc owes $250,000.  “Quit complaining, you brat!”  You might exclaim, “It’s pretty good money even if it’ll take you awhile to pay off the loans.”

Actually, that’s true.  Some people work an entire year just to pull in around $20,000.  In fact, docs are still occasionally heading for the hills with just this argument ringing in their ears.  As he drives down dusty I-90 toward the incomprehensibly-named “Crow Agency” Montana (leave it to the Guv to name a town an agency), young Dr. SW thinks to himself, “Hmmm.  250k divided by 20k equals 12.5 years.  Working out here brings me substantially less in yearly salary, so that 20k will be all I can contribute to my loans.  But 12 years.  That ain’t bad.  I can take it.  Nice view, after all.

But here’s the problem…the REAL problem with Governmental loan repayment programs.  It’s very simple.

The repayment is taxed.

The English language is too limited to describe the stupidity of this.  The same entity that gives the money takes it right back before the hapless doc – standing in his new Wrangler jeans at the bean-mash and Chevy show – actually gets to pay those loans.  And the entitiy who paid the loan doesn’t think of themselves as the same as the entity who is doing the re-taking so they often don’t even mention this taxation concept to docs before they sign their contracts.

To someone’s credit (no idea who), they’re coming clean recently about the taxation issue, inserting a disclaimer into their recruiting material.  Jammed forgettably into the back of the glossy packet I received extolling the virtue and adventure of working on the frontier, was this:

Participants in the LRP (loan repayment) will be paid up to $20,000 per year for signing a 2-year LRP contract and agreeing to serve full-time clinical practice at a designated Indian health program priority site in the United States.

It should be noted that LRP benefits have been ruled to be subject to FICA (social security) taxes.  This means that 7.65% of the loan repayment amount will be withheld and sent to the SS Administration.  Additionally, 20% of the LRP contract amount will be sent directly to the Internal Revenue Service to assist in paying the additional income taxes incurred as a result of participating in LRP.

This means nearly 30% of a doctor’s loan repayment grant is re-taken before it can be applied to the actual loan.  And remember, the base salary of rural docs is significantly lower than that of city counterparts, so the grant repayment is important.

The system needs repairs on many levels.  Universities need to charge less (maybe landscape less or something).  Banks need to make funds available at less profit.  Training needs to be shorter – everywhere else in the world, doctor training is 6 years after high school and then residency.  In the U.S. the training takes 8.  And a big part of the solution needs to be Government programs that are genuinely viable, moral and rational.  The current system tricks doctors into taking low-paying jobs in distant lands and traps them there by helping them with much less of their loans than they expected.

There’s lots of things that need fixing, but one of the first should be to stop all the governmenting.

The Family’s Doctor

Being a doctor to your family is tough. I didn’t think so, at first, but it gets harder to deal with as time goes on.

When I first became a resident – an actual doctor, in some people’s minds – I was flattered whenever someone from the family wanted to know what I thought. But further in to training, I began to see how much of medical diagnosis is based on the systematic physical and historical evaluation. Family and friends just dropping questions about real problems on me began to feel overwhelming because I knew I couldn’t give them good medical advice. Furthermore, other than saying things were fine…I couldn’t help anyway. “Go to the ER,” or “All good, dude, don’t worry about going to the hospital…just don’t use that hand anymore” were about the only 2 things I could say. Then, they take your word for it because you’re a doctor and you should know about these things and you worry that something will go wrong.

I’ve found that this conundrum is even harder to manage in my immediate family. With 4 kids, things happen all the time that could benefit from a primary care doctor’s evaluation. Additionally, with me working constantly – taking care of other people’s kids, as it were – you can imagine how hard it is for my wife to take one kid in to see their actual doctor rather than just having me check them out. But in the U.S., there’s all kinds of ethical issues with doctors taking care of family members. We’re strictly forbidden to take care of family members whenever they’re in the hospital – bastion of regulation and compulsive ethics that it is. In the clinic, things are a little more relaxed, but not by much. The general thinking is that doctors won’t be able to make objective medical decisions about family members. As if the decisions before us amounted to, “Foul insurrectionist of the imperial realm…OFF with your hea-! *Gulp* Wait a minute, aren’t you my kid? Well, OFF with your pigtails, then!”

jordie.jpgI can say that there’s some truth to this bias thing, although I wish there was some room for practicality. When my 3-year old daughter fell on a display rack at the grocery store and avulsed the tip of her left ring finger – her WEDDING finger, potentially – all I could think about was whether or not a new fingernail was going to grow back. As a doctor, I was worthless in the ER. Never mind distal tarsal functionality. Never mind osteomyletis or tendon rupture. WHAT ABOUT THE FINGERNAIL, YOU IDIOT KNOWNOTHING DOC!? SHE’S GOT 2 SISTER’S, YOU KNOW…FINGERNAILS ARE IMPORTANT AT MY HOUSE! Incidentally, it was around that time that I looked down at her pt. data armband and realized that based on the totally wrong birth date I’d given the front desk, my daughter was now in their system as a two year old male.

I also remember being quite an idiot for the birth of our 4th kid, which was via C-section. Just before the surgery started, I’m sitting in a chair at my wife’s head and a drape separates us from the surgical action about to start below. The doc says to me, “Hey, you recently finished med school, right?  We’re just about to get started here.  You can come down here an help or watch if you want” I about retched. Good GOD, man! Are you some kind of sadist? You’re about to eviscerate my wife! For the love of all that is holy, next time I want to watch someone commit seppuku, I’ll find it on You Tube! “Uhhh. No thanks.” I managed, severely nauseous and dizzy.

Many other countries see this issue differently. The idea that your son or daughter is a doctor means you have someone who you can implicitly trust in the medical field. You also have someone who you know will listen to you and give you the care you want (and won’t be bought off to kill you). Nobody’s going to sideline you or ignore you or mess something up if it’s your own kid who is taking care of you. In many countries, when children become professionals, there is cause for celebration because of how it will help the family, not the child.

I recently was wrestling around with my two oldest kids in our front yard. Just prior to ultimate triumph over both of them at the same time, my crafty 6 year old intertwined her entire body in mine and toppled me to the ground. In the process, I stepped on her wrist, which happened to not be in our yard anymore, but on the sidewalk. She cried, hard. In response, I performed “surgery” – a silly act where I make noises while pretending to be cutting and sewing.  This usually makes the injured tyke laugh while giving me a chance to actually examine the injury, and she seemed ok. No crying about it that night. But I a sliver of concern wedged itself into my comfortable analysis the next day when we noticed her trying to write and color with her non-dominant hand. “What’s wrong with your hand?” Mom asks, concerned. “It hurts where Dad stomped on it.  Better if I don’t move it.”

Great. I just broke my daughter’s wrist. In a perfect world, I could just call the radiologists (most of whom I know…except the contracted film-readers in Bhutan or wherever) and say, “Joohh! Hey, Geoff here. You remember my 6 year old from the BBQ last week? Yeah, need a quick zap of her left wrist. If you would, look for a distal ulnar fracture. Yeah, will send her right over. Thanks so much.” Kid gets zapped, rads reads, says minor fracture, I take kid into my clinic and wrap up her arm in a cast for a few weeks myself. Cost to me = some time and $0. Alternatively, Xray is negative so we skip the casting step and cost to me is less time and still $0.

This isn’t how it would work, though. I have to work, first off, so my wife (all alone) would need to do the following: Take all 3 kids to clinic. Scream at two littlest ones as they expand their imagination in the waiting room.  The youngest is dragging his tongue along every surface he can reach…for some reason Freud described having to do with sex that nobody understands. I pass my family 2 or 3 times, unable to help in any way because I’m busy. Eventually, another doc who knows about as much as me – but “scrubbed” of bias – sees daughter. Youngest has now partially swallowed a reflex hammer. Doc learnedly proclaims, “Daughter needs an XRAY!” Film ordered. Wife stops at hospital financial aid office to explain that said hospital pays dirt and we need assistance. 45 minutes later (youngest now gnawing on some old guy’s cane), cheap(er) Xray is granted. 2 hours later, Xray is positive. Child needs cast. Clinic closed. Not sure what kind of break. Best evaluated by orthopedic doc. Ortho doc (avg income $700,000 per year) does not give financial assistance (“Doesn’t your husband work with me in the OR sometimes? Coool. Here’s your bill, mam.). Normal break, needs cast. Kid heals. All done. Total bill = $3500 because of Dad’s stupid, clumsy feet. Dad now eyed suspiciously by CPS drones who wonder what kind of father figure would initiate non-sexual contact with their child.

In Israel, where I trained, there is a term roughly pronounced “protexia”. It means that if you work at the hospital, you get a break. It’s understood that you’re helping out as many people as you can, and when you need help, the organization pulls together to get you taken care of. Not here. You do it by the book. The book written by Americans with American medical ethics.

So we didn’t take our daughter to the doctor, despite the irony that she lives with one. We decided instead to just sit around biting our nails about the issue, hoping she’s alright. Just like most Americans with crummy or non-existent health insurance who work full-time. But at least the bone doc’s doing alright.