Tuesday, December 18, 2007

Med Schools Fail at the Business of Medicine

I have the pleasure each year of interviewing some of the brighest individuals applying to our categorical and transitional medicine residency programs. So far, I have asked each of 9 interview candidates to answer this question at the end of their interview:

"What do the numbers 99233 or 99244 mean to you?"

Without exception, each of them sat dazed.

Then I asked them, "What's the difference between an ICD-9 code and a CPT code?"

"It has something to do with billing," most said but not one knew the difference between the two.

Is this acceptable? Is it responsible to leave our medical students so woefully unprepared to enter the big wide world of medicine as it exists today?

Each of the students got an "A" for their efforts and idealism, but the programs from which they came received an "F" in teaching the business of medicine.


Image reference.


Unknown said...

Medical schools trail well behind most professional schools in preparing students for life in practice.

While one might think that the system of medicine might be more important to know than advanced biochemistry, the focus on basic science in the Boards has seriously curtailed the ability of young doctors to navigate the complicated business aspects of health. One might wonder how they have prioritized this aspect-- but if you go down that route there are many priorities you could question.

I personally had 1 lunch on health systems prior to creating my own health policy elective at USC (which now has spread into portions of the 2nd and 4th year curriculum).

The bigger question is where can docs go to learn--I spent 4 years at McKinsey. Others have spent time in banks, consulting firms, think tanks, or policy shops.

Ultimately, one must question why process, business, transparency, and accountability are treated as undesireable topics by the majority of practioners.

Anonymous said...

imo, those are things you should learn in residency, rather than medical school.
i bet most residents on the way out the door still couldn't answer the questions. at that point, whose fault is it? i would argue the residents have some responsibility to prepare themselves for the world and if they aren't taught it, they need to learn it themselves.

DrWes said...


While I agree that the majority of such eduation should prepare residents for the "real world," medical students, too, should be exposed to what Independent Urologist coined as the "Paradigm Shaft." Our medical students should know, early on, what they're getting in to: it might just cause one to change career paths. But then again, that might spell disaster for some residency training programs.

Richard A Schoor MD FACS said...

Amazing, though I suppose not surprising. I recently came upon the notion that residency directors could and should take a more active role in training residents for the business side of medicine. At the very least, all students or residents should have a curriculum in the history of the business of medicine. Only through a knowledge of history, can future mistakes be avoided.
Anyway, thanks for this important post.

Anonymous said...

I assume from your intro that at least they got an 'A' in general medical knowledge. :)

I think the medical students coming out now are more 'real world' than ever. Unfortunately I think patients have a lower and lower view of physicians than ever before.


Enrico said...

As a current med student who is older and cut his teeth in the "real world," I agree with your statements in spirit. However, I also believe 80-90% of what's relevant in this area belongs in workshops or the like in residency.

Sure, one can add a "business" course block along such topics as ethics, public health, etc. in the pre-clinical years, but beyond "exposure," what's the point? It still would have little real-world value any more than "ethics" coursework from a book does until one is face-to-face with real decision making AS the decision-maker.

People who are interested in the business of medicine avail themselves of MD/MBA-type programs. Those of us who couldn't care less see all of this as a [looming] necessary evil, getting in the way of an already crowded amount of information we're still trying to learn. It's a different mentality altogether when one has already "mastered" one's craft and can focus on other things.

Savvy students read more than their textbooks and know very much how the wind is blowing these days; they will make their decisions with these data/trends in mind. Clueless students will remain as such, regardless what course you create to spoon-feed it to them.

Dr. Deb said...

It really is sad how the business aspect is missing in the curriculum for many professions. Being business savvy and all that comes with it is important!

Anonymous said...

You're right, medical school is not business school, nor should it be. Teaching medical students about ICD-9 codes and reimbursement procedures is meaningless because so many things will change in the near future. Further, medical students do not take an active role in the billing process and therefore should not be expected to know how hospital billing works. Most students are trying to get by learning about disease and disease management. To start piling on teaching and billing would be an unnecessary burden. Hence, why residency is a much better place to learn about the business of medicine.

Unknown said...

I think a lot of you are really missing the point. Neither med school nor residency gives medical professionals a strong foundation in how the system works.

You're right in specific billing codes would be overkill at this level-- but how billing and insurance work, who the other players in the system are--how they work and what their incentives are (e.g., employers and insurance companies, PBMs, disease management, hospitals, pharmacy, government, pharma/device) would be a terrific overview of the forces they need to understand to be good advocates for themselves and their patients.

Currently, 99% of med students have no idea how health care works, is funded, has changed, etc-- which leads to new docs being focused on tactics (e.g., upcoding/ downcoding) vs. strategic decisions (how to start a practice, going cash vs taking insurance, becoming a specialist vs. primary care, etc).

DrWes said...


You are right on target. Each of us are quite aware of the rigors of medical school and residency. But I, for one, was completely unprepared for the real world after leaving medical school (and even residency) and was struck my my complete ignorance regarding the business of medicine. I find that residency programs, like medical school, continue to rarely have ANY introduction or background courses regarding various economic issues important to young physicians. Perhaps it is because many of the professors have grown up in the protected confines of academe and not experienced the many challenges of private practice or the strategic inner workings of the complicated world outside their academic center. Consider contract negotiations or the laws regarding restrictive covenants when you sign your first contract, not to mention the government bureaucracy and the political forces that shape the terrain of healthcare today. If I hadn't encountered these same issues, I wouldn't be making a big deal about this, but I did.

Students and housestaff are just lambs being lead to slaughter if they ignore these important aspects of their professional career development, whether in med school or residency - and in my book, it's best to start early and at least gain a basic familiarity with the business of your upcoming life.

Goatwhacker said...

I would take it a step further and say that many doctors never do learn the business side of medicine, particularly those in academic medicine, military or government-sponsored practices, HMO clinics and many large groups. While it's great to be able to practice medicine and not worry about the business side, it does tend to lead to a skewed view of medicine and a lack of understanding about the import of day-to-day decisions.

Unknown said...

I agree with the sentiments regarding delaying the teaching of billing and the business side of medicine. However, I also think payors and HMOs like us to be financially ignorant. When I fist left medical residency, I worked for a staff model HMO where there seemed to be a great effort to separate our professional lives from any financial realities. I went back to do a cardiology fellowship and subsequently was a junior faculty for a few years. Once again, we had ancillary staff filling out fee tickets, reviewing our charts to complete our inpatient billing etc. To be honest, however, I doubt most people in our division would have bothered to do the billing.

Does anyone know about dental schools and their curriculum? I belive most dentist have solo or samll practices and need a certain amount of business savvy to survive. It this part of their dental school curriculum?

Anonymous said...

I teach an 18 month business of medicine seminar in the department of surgery at Ohio State to seniors that is now attended by other residents. Covers everything from buying insurance to contract negotiations to Stark. Starting to make a dent in the ignorance out there! They find it very useful. Good for recruitment as well.

David Joyce MD said...

I am a physician finishing an MBA at Johns Hopkins. If I had know one tenth as much as I do now it would have changed my life. I ran a $5 million practice with a C.P.A. at the helm and it was like having your feet stuck in cement. The future of medicine depends on those who can adapt to the business environment, those who don't will fall by the wayside.