Money: The elephant in the resident’s room

[Editors note: This Guest Editorial has been adapted with permission from an article in the Spring 2012 issue of Soundings, the Pennsylvania Academy of Otolaryngology-Head and Neck Surgery's newsletter.]

For one academic year, I pursued clinical research as part of a T32 NIH-funded research year primarily focusing on cost-effective medicine and the containment of operating room costs. Having converted the last desk in our otolaryngology resident room to a makeshift office, I spent several hours a day at this work space typing away on the computer. Peripherally, I saw and heard residents scurry in and out of the room on their way to and from the operating room, the outpatient clinic, and the hospital wards. Through interactions with them, as well as unintentional eavesdropping on conversations among other residents, it seemed that one topic, in particular, recurred with regular frequency: money. "I would love to know how much the attending gets paid for that in-office scope"; or "How much do you think the medical center charges for OR time?" or "I heard that the gap between private practice salaries and academic salaries is closing. I wonder if that's true."

What was more curious than the regularity of these sound bites was the tone in which these statements or questions were made. It had the feel of celebrity gossip-part guilt, part pleasure. Why? As front-line care providers, we focus on the care that may improve patients' lives surgically, and almost completely ignore its devastating impact on them financially. We dismiss thoughts of our future income in the midst of sick patients to avoid feeling overly self-indulgent. Instead, we wait and Google from our home computers "otolaryngologist salary Pittsburgh" or hold off our monetary investigations until our first job offer.

Something doesn't seem right. Why is the relationship between residents and printed presidents so perverse? I think the reasons are multiple and far-reaching. For people like me, it starts early. I grew up in a household where money was seldom discussed. My father was a radiologist, and I knew enough to realize that we were "comfortable." I went to college and didn't have to worry about student loans because in Indian, as in some other cultures, if parents can afford it they dutifully pay for the entirety of their kids' education, from undergrad to medical school. But by the end of college, all premeds, regardless of their family's financial situation, stand together to witness a fundamental divide between themselves and their fellow graduates.

Our business-minded pals wake up one morning and prepare themselves for the real world. They don suits and negotiate job contracts-sometimes involving multi-thousand-dollar signing bonuses. They talk to each other about mutual funds and welcoming gifts for their soon-to-be secretaries. We, on the other hand, feel more nerdy and sheltered than ever, talking about histology microscopes and new backpacks. With regard to money, we tell ourselves, "It's not important right now; I'm sure well learn about it soon." Or so we think.

Medical school-those 4 years of isolated medical trainingbegin one's steep descent into financial ignorance. I recall putting in my first order on a patient as a third-year medical student. Bedside chest x-ray, AP view. Right after my senior resident approved the order, a man in a gray scrub top wheeled an x-ray machine right past the nurses' station and to the patient's room. "Wow!" I thought. "I just made that happen by pushing a couple buttons." The reckless power trip of hospital ordering persists for years. Reckless, because most of us are without concept of the costs we inflict upon the patient in return for providing healthcare.

Recently, some university hospitals have begun displaying the costs of diagnostic laboratory tests during order placement. This idea seems dangerously foreign to many who fear that the imposition of monetary variables might cloud clinical judgment. As a result, the majority of us graduate from medical school as another class armed with the dangerous combination of medical credibility and fiscal ignorance.

Residency-we must make sure to carry out orders from attendings, fellows, senior residents, and requests from nurses and, of course, make sure that our patients are safe. The furthest thing on our mind is calculating the patients' hospital bill. If a patient brings up his/her financial concern to us, we reflexively offer the phone number of the floor social worker. Reflexes are protective in nature, and this one is no different. We have realized that we are wholly unequipped to navigate the complex health system, and it is best to keep our distance from terms like insurance, reimbursement, and hospital charges. Moreover, as we bear the frequent sleepless nights of being surgical interns, something else happens. We develop a newfound cynicism of our position as a modestly compensated skilled laborer. These feelings of bitterness and system ineptitude coalesce to form a deep, enduring skepticism toward medical businesspersons. Now, not only have we become ignorant of the inner workings of the healthcare system but mistrustful of it and its overseers.

It is clear that the divide between medicine and business occurs even before medical school. Unfortunately, instead of marrying the two elements, medical school and residency serve to actively widen the chasm. After finishing residency, we are expected to seamlessly bridge the decade-long gap of financial know-how. Impossible. In order to preempt this unfavorable end result, system-wide change is in order. While the primary objective of this editorial is to shed light on our current state-not to try to provide simple solutions for this complex dilemma-a couple suggestions seem worth mentioning.

Medical schools require significant bolstering of education in health systems in their curricula.1 In addition to formal education in United States health systems and policy, more subtle issues involving physicians' dollar value to society ought to be addressed. We must be challenged to come to terms with our role as "for-profit healers" so that we can speak openly about the effects of our monetary might.

Residency education must also do its part in formally preparing its offspring for the economics of individual practice. For instance, trainees should be able to demonstrate fluency regarding hospital charges, hospital costs, and physician reimbursement for common specialty-based services to understand the perspective of the patient, payer, and provider.

Until medical education spotlights the economics of medicine, we will continue to converse sheepishly in resident quarters about the invisible driving force behind our profession. As a result, young physicians and surgeons will remain ill-informed and, more importantly, conspicuously absent from the group of leaders controlling the fate of American healthcare.

Reference

1. Patel MS, Lypson ML, Davis MM. Medical student perceptions of education in health care systems. Acad Med 2009;84(9): 1301 -6.

Raj C. Dedhia, MD, MS

Department of Otolaryngology

University of Pittsburgh School of Medicine

Pittsburgh, Pennsylvania