The Price of a Pandemic: The Good Doctors

As ER physicians & medical residents risk their lives, are they compensated fairly? How much are doctors worth during a crisis? We talk with Dr. Nitin Vaswani- John Hopkins alumni, trained clinician and healthcare investor on the future of digital health.

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Last week, we heard about the incredible pressure on hospitals during this pandemic and how it’s affected nurses specifically. Today, we turn our attention to ER doctors at all stages in their careers... from the residents to attending physicians. And just like other healthcare professionals, they too are putting their lives at risk.

The cost of education to be an MD is high, resident salaries are low, and starting one’s own independent practice is harder than ever. With that said, there are many young MD's (residents)  who are working on the frontlines right now. The question is - are they being fairly compensated?

Episode 9: The Good Doctors - In today’s episode, I talk with Dr. Nitin Vaswani, a trained clinician, Hopkins alumni & healthcare investor. Currently, he’s spending his time pushing digital health initiatives, as well as helping hospitals transition into tele-health. We learn:

  • The current pay gap between doctors in the ERs and the one's senior to them.
  • How the hospital system works, and why it’s so hard to start one’s own practice.
  • Why hazard pay and loan forgiveness is important for healthcare workers right now.
  • The importance of digital health, and how COVID-19 is pushing that movement forward
  • How doctors can be compensated through tele-health.

Today’s episode also includes personal stories from two physicians on the frontlines. We thank them for not only sharing their stories, but also for giving us hope. A huge thank you to all the healthcare professionals out there! Stay safe!

Episode Transcript

MESH VO: Hi everyone, Mesh here from Talk Money, and welcome back to The Price of a Pandemic, our series where we discuss how the coronavirus is affecting the economy, business, markets & investing.

If you tuned into our show last week, you heard about the incredible pressure on hospitals during this pandemic, and how it’s affected nurses specifically. Today, we turn our attention to ER doctors, at all stages in their careers, from residents to attending physicians. This is wartime for them, and the stakes have never been higher. But their intense workloads and ability to support themselves are vital issues, ones that are hugely influenced by the political structure of the medical industry. It’s the last thing they should have to worry about at a time like this, but sometimes it takes a harsh light to illuminate the cracks in the system.

Innovations around digital health are crucial, for both doctors and patients, whether we’re sick or healthy. As healthcare workers continue to risk their lives, are they being compensated fairly? How much are doctors worth, especially when they’re so crucial to surviving a crisis?

In today’s episode, we learn more about the future of digital health and what it’s been like for the early-career doctors in the trenches. I talk to my good friend Nitin Vaswani, who’s an investor in the healthcare sector, as well as a trained clinician in Washington DC.

Nitin: [00:00:40] My name's Nitin Vaswani and I do a bunch of things. I started my career off in the medical profession, so I'm a trained surgeon and then I made a switch, went into the financial world, had a short career on Wall Street, and then [00:01:00] actually shifted toward investments in healthcare diagnostics and digital health. [00:01:04] Beyond that, I do a lot of on the ground clinical training for community health workers in low income communities. I grew up in Indonesia so part of my interest in working in medicine has been to support marginalized communities or low income populations // who need care the most, and that's where I spend most of my time these days.

Mesh: [00:02:48] That is amazing but while you're not in Indonesia or these places overseas, you're [00:03:00] based in Washington, DC no?

Nitin: [00:03:02] That's right. [00:03:14] My main focus today is in digital health. So I support developing healthcare diagnostics and digital health companies and bringing those types of companies and solutions to [00:03:30] both healthcare providers and to patients in large academic settings and also directly in the community.

Mesh: [00:03:37] And right now in the midst of COVID 19 are you focusing more on working in the ERs or with patients directly?

Nitin: [00:03:51] Yeah. In fact, it's become even more important as we try to find a way for healthcare workers to continue to provide services while they're at home. I know this sounds like an oxymoron. So, for example I spend time working at a hospital in DC and they were trying to migrate all their care from face to face care to telecare. [00:04:49] So before COVID 19 hit // the number of telemedicine services were in the [00:05:00] single digits, all of a sudden it's ramped up to the hundreds and now to the thousands. Right? So you're seeing this major shift // in terms of what healthcare needs to be, and this is something that I've been kind of screaming about to the // healthcare community and saying, we need to do more of this. [00:05:16] And we need to do more of this for a variety of reasons. First and foremost, it's protecting healthcare workers. But secondly // it’s actually protecting patients who are coming to the hospital if they don't need to be there, your chances of getting exposure to an infection // or other things within kind of a closed unit is actually higher than you being within the comforts of your own home.

Mesh: [00:06:09] And Nitin, can you walk us through your medical career and how you've ended up now in this position?

Nitin: [00:06:24] So I grew up overseas. I went [00:06:30] to undergrad in the US  and then I went to medical school, back home in Australia, and it was a very similar system to the US for four more years.  And then I did five years of residency, so that's 13 years. // And then after residency I moved to Baltimore, to Johns Hopkins, where I did a research fellowship on top of doing [00:07:00]  healthcare business classes. So I did an MBA as well as a public health degree.

Mesh: [00:07:36]  So you basically say it takes anywhere from, you know, 10 to 13 years to become an MD. How much does it cost on average, for the ER physicians that are in there right now, the front line, what is the average [00:08:00] cost of going through medical school and everything that comes with that?

Nitin: So the average medical school debt, kids getting out of medical school today, every medical school debt is $200,000. Now the cost of it, if you're an undergrad that said, you go to a private school, let's say it's 40K a year, it's 160K you go to a private [00:08:30] medical school, now there’s 60 to 70K a year. [00:08:32] Alright that's 280K for med school. For undergrad obviously that has some differences if you go into a state school or private school. [00:08:52] Now some of us get scholarships, some of us our parents help us or other colleagues help us [00:09:00] but the average debt coming out across the board. Most kids are coming out of med school with $200,000 in debt in the United States.

Mesh: [00:09:11] And are younger MDs that are getting out of med school able to pay off their student loans sooner?

Nitin: [00:09:20] Yeah. No. So and this is where I think this pandemic has created maybe a little bit of tension or differences [00:09:30] of opinion when it’s coming to younger physicians. [00:09:37] I got into med school in 2011, //it's only been about eight, nine years, whereas the more senior guys have been out for much longer. So the average medical resident pay in the US today is 60K. The lowest paid residents are those who work in family medicine, the emergency room physicians, internal medicine and these are the folks that are the most in demand during a pandemic, like COVID 19. [00:10:21] The guys that are getting higher pay during residency, so // the [00:10:30] surgeons or anesthesiologists and so on their pay is actually higher. Now, then you take that one step further where you're getting out of [00:10:41] a residency and you're an attending, the average pay there is about $300,000 a year. [00:10:57] There are huge gaps there as well, right? So if you're a neurosurgeon, [00:11:00] super specialized you're making more than the 300. if you're family medicine, less specialized, or ER, less specialized, you're making less or are in and about the average.

Mesh: [00:11:14] And who's actually paying that? Can you explain a little bit about how the business of that work so we can just [00:11:30] understand where the pay comes from?

Nitin: [00:11:31] When you're a medical resident, the pay comes directly from the hospital or in some cases it's sponsored by bodies like Medicare or [insert “the”] government. Now on the attending side, when you become kind of a full size physician and you’re out of your residency there are huge differences in what's happening. [00:12:08] Previously a lot of physicians came together, created a private practice [00:12:30] and then provided their services to the hospital. [00:12:34] Private surgeons or more specialized physicians, right? For a lot of us, who are on the front lines, for example, ER, or internal medicine or in family medicine or working in kind of academic settings where we're salaried [00:13:00] part of the reason that we're salaried is because it provides a certain level of security being able to work within the large academic setting or a large hospital setting. [00:13:30] But that's been a big shift. In the past most physicians, I'm talking decades ago would come out of medical school and then set up their own practice. But because of rising rent, rising legal costs, [insert “and”] billing costs there's been a huge shift in that paradigm.

Mesh: [00:13:52] And so that that would mean kind of similar to affording rent // in big cities, you end up moving to [00:14:00] smaller cities or the suburbs?

Nitin: [00:14:02] Well, there's also a lot more opportunity, right? I gotta be clear here. I'm talking about the younger physicians that are coming out a lot of us kind of are trying to go to rural areas because there is a lack of medical services there. So it gives you an opportunity to kind of serve a patient population [00:14:30] where it isn't as competitive. [00:14:34] Like you're in Washington DC or in New York City, there are a lot more specialists around. [00:15:15] So let's say a bunch of us are coming out of medical school. We have, each of us have $200,000 in debt. We don't have a lot of capital to invest into a private practice, right? So those are kind of barriers for [00:15:30] us to jump straight in and start our own practice.

Mesh: [00:16:47] You had mentioned to me that you were doing some volunteer work in the emergency room with patients.

Nitin: [00:16:57] Yes, yes.I was doing [00:17:00] that outside of the US I was spending time with communities where we were seeing flares. I was helping clinically on the ground was in some of these committees where people were in acute respiratory distress, they were having a lot of trouble breathing and didn't know why they were having trouble breathing. [00:17:45] So we were kind of teaching and supporting local health workers doing really detailed training on what to expect for individuals who are getting exposed to the disease. The other part of it was educating the community and what they could do. And then more importantly, when to [00:18:30] seek treatment. What we were seeing which was really difficult for us at least who were volunteering in this space, was seeing this huge surge of people coming to clinicians or to smaller community centers and asking questions. And it was actually making the situation worse because you're having these groups of people all lining up and coming together really concerned about [00:18:50] about the virus. 

Mesh: [00:20:07] In the case of the United States, what's going on right now with the hospital systems? Are they severely overloaded?

Nitin: [00:20:24] Yeah so you're having [00:20:30] certain areas which are overloaded and certain areas where cases have severely come down. [00:20:33] So like in DC where I'm supporting digital health efforts. About a month ago, what we were seeing was this dramatic surge of individuals coming into the hospital. [00:20:49] They were [00:21:00] coming to the ER and asking us, [00:21:11] I can't feel certain things in my face, do I have COVID 19? or I can't taste which we later found out to be a symptom of COVID 19 was I can't taste or smell And you were seeing this surge of individuals come into the hospital whereas these questions can actually be answered without [00:21:30] coming into the ER. So our immediate response to that from a clinical perspective here was how do we stop these individuals from coming to the hospital? How do we provide them care and respond to their questions in a way to make sure that they're safe and our health care workers are safe at the same time? [00:22:42] Because being on the front lines whether it's in the ER here in the US or even in the trauma centers overseas for a lot of us it's really difficult to deal with that volume of patients and give individuals [00:23:00] the appropriate time to actually address all their concerns. There needs to be a big shift in terms of how we deal with [00:23:08] this worried well population and those that actually really need intensive care.

Mesh: [00:23:30] So right now, with people who are actually very sick or in the hospitals and the [00:23:30] doctors and the nurses that are on the front lines. What happens if they get sick and they can't work? What does that do to the system?

Nitin: [00:23:38] It does a lot of things. I mean, number one is it puts a lot of pressure on other people around them. [00:23:47] I mean, uh, I have a sad story to share. A very good friend of mine who works in the ER two of her colleagues actually got affected by COVID 19 and [00:24:00] passed away-

Mesh: [00:24:02] Oh man, I'm so sorry to hear that.

Nitin: [00:24:03] And it's just, it's devastating to hear that. And the reason that that happened was because it was a lack of personal protective equipment. [00:24:11] So then what happens? What happens is their workload is transferred over immediately to her or to other individuals who are also working in the ER. [00:24:30] The second part of that is trying to make sure that clinicians are working at a safe space from one another. [00:24:39] So if doctors and nurses are getting sick, they're not working that's really the simple solution. And if they are working when they're ill there are serious consequences to that.

Mesh: [00:25:15] Right and generally for the doctors on the front lines, where are they in their careers? [If possible to edit without sounding cut up: Who are these doctors right now that are in the ERs and risking their lives?]

Nitin: [00:25:32] // It's // young residents // who are starting their careers, all the way to // attendings as well. // In a typical ER, you'll have, [00:26:05] one or two attendings kind of manning the floor. Then around them, you'll have this // army of residents or other health care workers. So nurse practitioners, physician assistants, nurses who are supporting the decisions that that the, that the attendings are making. // So if you're looking // at the balance of // the healthcare worker, there’re much fewer attendings compared to the army of healthcare workers who are supporting them. // [00:26:50] They work as a team very closely, but as a large group of // healthcare workers supporting the physicians decisions. So this // creates sometimes a little bit of [00:27:00] tension.  And we're seeing this in New York // where some medical residents are saying, hey look // I'm putting my life on the line here, right? [00:27:11] I'm getting paid // 50 to 60K a year, putting in these // heavy shifts // am I entitled to some hazard pay? // [00:27:23] Am I entitled to // perhaps some student loan forgiveness? // [00:28:28] But on the flip side of it, it's hard for us to [00:28:30] negotiate // for the younger physicians because we're thinking, well // it's only a few years. I'll be on the opposite side of this eventually. // I just got to stick through this and eventually I'll be okay. [00:28:47] Because // I'm going to get that paycheck at the end //  of this. So it’s kind of a fine balancing act, you don't really want to burn those bridges in terms of being upset. //

Mesh: [00:30:16] You mentioned to me that more senior level doctors control a bit of who's performing what [00:30:30] procedures and how much is charged. Is that something that you can explain to us in terms of how the hierarchy works?

Nitin: [00:30:40] I can answer this question twofold. So, one from a COVID-specific perspective. As I was mentioning for a lot of younger doctors who've been asking for hazard pay or some kind of financial compensation. The accusation is sometimes oh, you're not dedicated to the cause. Or you're not [00:31:08] sacrificing enough for the cause. And it's kind of disheartening for me to hear that because, you know, I see these young doctors every day putting their lives on the line and then being accused to kind of say you're asking for money. You should be more committed.  We have a duty of care. We care about the profession that we have. At the same time, we also need to look after ourselves. On the procedural side with COVID almost all elective procedures have been canceled // which I think has been the right move [00:32:22] so we're only performing procedures  that are necessary. In a post-COVID world let's say a procedure comes //that needs to happen. Most of the specialists that are  highly experienced  or have [00:33:00] // this // large patient following usually gets the referral. [00:33:06] For a lot of us  younger individuals who are just coming out to get more experience or where we're practicing our skills, we're usually // not getting this kind of a large referral base because as a young attending  [00:33:21] you're trying to // find your way in this community. It's just like any business really, right? And I think that's fair and in many ways they've been able to build a kind of rapport or network to make sure that they're getting the bulk of the referrals. 00:35:05] So what ends up happening is a lot of us are seeing opportunities in more rural settings or in more smaller towns where there is a lot of large service gaps.

Mesh: [00:35:17] And so what would you like to see change for your fellow doctors [take out if possible: who are risking their lives]?

Nitin: [00:35:24] //  I mean // many things. // [00:35:46] Provide care // in a safer way, and // in a more effective way. // [00:36:35] How can physicians practice more preventative health by getting compensated for that? There has to be a shift, right? [00:36:44] // It's very // acute-centric. It's like you're sick. You come in, we'll look after you, see you later. We're not actually then spending a lot of the time on the preventative side, which I think we need to invest more time in and finding ways to // get // physicians to be [00:37:00] compensated for their preventative care is significant. [00:37:42] So in the healthcare providers side of the health system side, more ability to provide telemedical services. I want to be able to respond to questions when I have time. So if somebody has a question about COVID or about a symptom, I should be able to answer that question for you in a way that's safe and in a secure environment. And I should be able to do that constantly because that does a few things. [00:38:16] One, it actually expands my ability to practice beyond the walls of a hospital. And secondly, it actually helps me // start becoming a health coach. [00:38:34] We don't need more acute physicians. We need more people to help people eat better, exercise more, learn how to take their medications the right way, wash their hands, for example, with COVID practice, social distancing. People need support with that on a daily basis. [00:38:50] My favorite line is like, Oh, you've come to see me. Great. I'll see you in four to six weeks. It doesn't help. What [00:39:00] you want is constant communication to support people when there is uncertainty. [00:39:47] How can we be utilized as physicians not only to provide care directly, but also on a systematic level to make sure that these types of pandemics are [00:40:00] handled earlier or this information is being spread earlier and individuals are actually interacting with their clinicians earlier instead of when it becomes too late.

Mesh: [00:40:11] We've been hearing about how much trauma and stress doctors are experiencing right now. What's happening in terms of mental health support for them either now or when the pandemic slows down? 

Nitin: [00:40:40] Yeah, there's a few things that we've done. So it's funny, we used to say, oh yeah, let's create peer to peer groups for our patients. So a group of patients who have the disease, let's put them in a group community so they can talk to each other, right? We're doing that now. [00:41:00] Like, I'm talking to my ER colleagues or my trauma colleagues globally my surgeon friends in Australia, my ER friends in the UK, we're all talking to each other, hey, what are you doing? What are you seeing? [00:41:10] And we're on the phone a lot, actually supporting each other more than anything else mentally. And that's been, for me at least, incredibly helpful. [00:41:30] Just talking in general about what[00:41:36] each of us are doing differently for treating individuals who have COVID. And for our colleagues who are affected by it, how can we support them better? I mean, some of these stories that I'm hearing of how my ER colleagues in the UK are supporting their admin staff who, who actually got [00:41:57]  COVID they're going to their house, cooking for them delivering food every day, taking their kids to school. There's a huge rally around within the community to actually support one another.

Mesh: [00:42:10] That's amazing, man. Because there's only so much we can do to show our support to people working in hospitals right now. What would you like to tell the audience on what's the best way we can support our doctors?

Nitin: [00:42:30] I think be kind and provide gratitude. I think for a lot of us we love serving the community and we love to be there for everybody and sometimes just that small thank you or a warm smile really keeps us going. I think sometimes a lot of us can get lost in the details because we're just moving from one thing to the next. [00:43:03] And I think part of it is also our inability to stop because we're so stressed. I've been getting a few cards and a few thank you notes and that just gives me motivation to get out there again and support some of these communities who need help.

(Music)

(Doctors Voice Memo Outro Montage)

MESH VO: The overload on hospitals due to COVID-19 has changed a lot of things about our access to medical care. Even if you haven’t fallen ill with the virus, chances are you’ve changed your health habits in the past month. People are putting off routine appointments like check-ups and physical therapy. Elective surgeries and procedures that aren’t virus-related have been pushed, then pushed again. And when it comes to non-virus emergencies, how can we keep ourselves safe without putting even more strain on local hospitals? 

The answer is probably a combination of things, some more difficult than others: digital health developments. Continued self-isolation. Limited and structured reopening of the economy. And a continued effort to work on a vaccine, while testing the efficacy of herd immunity. This is a group effort, and nothing will work without everyone on board. In the meantime, we have to listen to our healthcare experts, because they’re putting their lives on the line, to make sure we keep ours.

I want to thank Nitin Vaswani for his time and for being so open and transparent with us. Thank you to Natasha and Burr for sharing your stories with us during one of the toughest times in your careers. And a huge thank you to all the healthcare professionals at the hospitals for doing what you’re doing. We’re so incredibly grateful for your work. Stay safe out there.

This episode was edited and produced by Olivia Briley & engineered by Maia Tarrell. Our music is by Blue Dot Sessions. Sign up at thetalkmoney.com for further deep dives and to hear other episodes. We appreciate you sharing this with your friends, and of course subscribing to us on Apple, Spotify, or wherever you choose to listen. Until next time.


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