This is a guest appearance of the bluebird of Twitter happiness known as My T Chondria. I am almost positive the bird does some sort of science at some sort of US institution of scientific research. The bird is normally exhausted by typing messages 140 characters at a time so I was skeptical but....well, see for yourself.
MDs and PhDs are considered to be some of the brightest and the most insightful people in the country. Indeed, look no further than the nearest MD or PhD and ask them; they will attest at great length to their exceptional smarts and individual importance in maintaining the sun orbiting the Earth. Yet for all the combined education there remains a fundamental lack of appreciation of how intertwined the fate of these two professions are - ranking right up there on the irony scale with Pakistan threatening to nuke India (they are geographic neighbors, so that’s ironic, you see).
For anyone who has ever worked at a major academic medical center, we are told ad nausea how important we are in understanding human health. Yet we do so almost exclusively in parallel universes. Asked what its like to try to work with an MD, a PhD will often tell you MDs are ‘erratic, ill informed and totally lacking in any understanding of what goes into doing real research’. Conversely, asked what PhDs do, MDs will likely reply ‘they like to present very complex diagrams, write grants and develop models of disease and pathology that have little to do with any case I’ve ever seen.
I get to surf between these groups; my primary appointment in a clinical department affords me a perspective that is unique in that I am able to pass as either an MD or a PhD on any given day. I spend the majority of my time running a research lab but I can scream “House! Put down the scalpel you jackass! All you have to do is order a chest x-ray and look for pulmonary infiltrates to know it’s not sarcoidosis!” with the best of interns.
Figure 1. “It’s a fan!” “It's a spear!” The hilarity of people in white coats looking at their own little microcosm of an elephant and being unable to appreciate it is actually a bloated endangered species that could kill them all. And by bloated endangered species, I mean academic medicine*.
*Author note: Am I going to have to explain all my jokes?
In drifting between these lands, I noticed the rifts earlier between ‘researchers and doctors’ which seemed vaguely amusing not so much now as first but as the business of academic medical is getting the shitte kicked out of it and PhDs think it has little to do with them.
In previous faculty meetings, I would watch tenure track PhDs glaze over as our beloved leader discussed the ‘blah, blah’ of clinical revenue streams.
Conversely, the MDs would eagerly reengage a new level of Candy Crush Saga as our chair commiserated with PhDs about pay lines and sequestration. (So clueless were the MDs about the recent plight of scientists that the esteemed journal JAMA even had to run an article in their online edition earlier in the year explaining sequestration to the primarily MD audience.)
At our most recent faculty meeting, there seemed to be a moment of real illumination between both groups that everyone in the medical center was screwed and better start making more widgets faster. Our Fearless Leader informed faculty that our hospital budget shortfall was progressing more quickly than we had anticipated even three months ago and vacations were canceled for faculty, more clinical hours were going to need to be booked and the bergermeister was coming to take all our toys (only two of these three have happened so far).
Figure 2. Predoctoral kitten downed by lack of understand of the health care industry on academic medicine.
Later that day, I took to on Twitter to vent and look for pictures of kittens doing cute things (see Fig 2 as evidence of my hard work). Many of my Twitter followers are porn bots, but at least 2 or 3 are PhD-types and aghast that my medical center was being so aggressive. There were many sad emoji’s sent my way and a flutter of ‘how could they’ and ‘oh, your poor little university’ that made me wonder what planet everyone is on and if donuts were as delicious there as they were here (see Storify by @mrhansaker here
EVERY medical center in the US is getting carpet bombed into financial oblivion by the economy, Medicare reimbursements and Obamacare. And yes, I assured my Tweeps, the amount of our gross national product that goes to health care is stoopidly high. But, a startling number of my PhD buddies were taken aback by the idea that those pesky ‘high health are cost’ they glaze over in faculty meeting or when listening to NPR is also covering their academic PhD arses.
So, for my PhD pals, whom I shall refer to as ‘People who are doctors only when they book hotel rooms’ (I’m kidding, I’m a kidder!), I wanted to run this down a bit further. If you have a medical center as part of your university, you have been riding clinician’s financial coat tails for a long friggin time. The indirect rate charged to granting organizations in no way covers operating costs for research. That takes an endowment or an additional revenue stream. Endowments usually come from long dead old rich doods. These endowments don't just sit in Scrooge McDucks cave. They get invested in things like the stock market. And the stock market got the shitte kicked out of not too long ago. Billions in endowment money were lost in the economic collapse - most Universities took 25-50% hits on their Scrooge McDuck funds. So, if you’re a PhD, you can take endowments out of the equation as what’s been filling in those pesky financial gaps between costs and expenses. No worries, you’re at a medical center so you have a revenue stream- your clinical enterprise. Sick people. America is ALWAYS good for some damn unhealthy and foolish folks who will make the worst choices possible and rack up a small fortune in insured and uninsured care.
Thank God for stoopid and unhealthy people, amirite?? This is even better because our Commander-in-Chief got an electoral mandate to insure everyone’s (ish) stoopid arse. More money for medical centers has got to be a win, yes? Not so much. Show me a medical center meeting its financial goals, hell even one that isn’t heading for a hundreds of millions of dollars of deficit for 2014, and I will show you a for profit medical center (read here: “not academic, so no jobs for you PhDs”).
The proverbial sky has been falling for research scientists for some time now as well documented by my kind host Drug Monkey and others with inferior blogs and better shoes. And indeed, MDs have been hounded into appreciating the genius that is the bench scientist. So valued are the basic researchers that they are sought after to heap more prestige on the medical center and an even better training environment which increases numbers of trainees, blah, blah.
Unlike clinicians, scientists have known the economic sky was falling for some time and have been zealously advocating the importance of science research bracing for impact. To the outside world, that looks a lot like holding your collective sphincters together as tightly as humanly possible and waiting for things to improve. Well-done people. Actually, you sort of sucked at advocating for yourselves as evidenced by the two of you who actually sent @nparmalee letters to hand deliver to your Congress Critters a few weeks ago, but I will need another bottle of wine for that.
The first warning to those PhD types in the 35+-age bracket would have been when Scamp-in-Chief Bill Clinton never quite delivered on his ‘peace dividend’. The one where all those pesky defense dollars would go to building a bigger, better, smarter American work force with futures in STEM (Dumber Bombs! Smarter People!). We would turn in our tanks and churn out better-educated versions of ourselves with outstanding oral hygiene to lead us forth into the new millennium free of disease and with cats with laser vision. Not only did we forget to provide sustainable growth mechanisms for STEM, we also neglected to maintain world peace and not screw the interns. Bill, you lovable rascal, at least you didn’t shoot anyone in the face. Just in the foot. Or both feet.
In the parallel world of MDs, who kindly request you simply refer to them as ‘real doctors’ for the rest of this diatribe, the pesky business of health care in academia has always been a house of cards. About 7% of MDs practice in the rare air that is academic medicine. This affords prestige, time for clinical research, collegiality, security and none of the business hassles of private practice, but about half the salary. Which, to be honest, is still a metric shitte ton of money especially if you do a bit of consulting. But now, there’s no research time, Medicaid is squeezing out every reimbursable dime and you are keeping the same hours as your hapless residents.
My take home from today friends is that the party seems to be winding down. Rather than recognizing that our fates are intertwined, MDs and PhDs frantically see more patients and write more grants and wonder when the sun will shine on us once again and society will appreciate our true worth. I have yet to see any evidence that for all the brain power and letters after peoples names, PhDs are even aware of that medicine money is research money. So you go put your blinders on and find that spear, and I’ll put mine on and grab this rope and no one will call it an elephant.