Comments on: 20 Questions: Michael Rack, MD [Sleep Medicine]

By: PG

PG — Fri, 09 Jan 2009 06:29:10 +0000

I am going to give you my own personal account of sleep medicine …. you can see some contrasts with Dr. Rack’s ideas.
I use to practice as internist for a while at a well known academic setting with a back ground in neuropharmacology and a big bag of published research.
I was initially thinking, I will be a pulmonary/critical care physician but the realities of practice of medicine and the fact that I was making these desicions when I was a bit older helped me decide not to go for CCM. I chose to have a better lifestyle basically. I was interested in the sleep medicine from many years ago so I explored it more and found it to be really interesting. I was lucky to be able to do a fellowship in the sleep medicine.
I found the practice of sleep medicine much more interesting than a lot of other fields that I have experience with (that includes meaningful experience with being closely involved – as a job – with the fields of trauma, vascular Sx, ENT, Lasers in medicine, bench and clinical research and internal medicine!)
I think a student should not forget that no matter what subspeciality they choose, they will end up having to deal with a few limited conditions and it is going to feel repeatative. Yes, in a sleep clinic you have to do a long semi structured interview. But, the analysis of this information and formulation of plan in these cases has been an absolute pleasure for me.
Some center focus on sleep apnea that’s when it can get boring. But if you manage to have a good name in the region then you will have consults for a lot of other issues . You can be seeing patients with other problems for up to half of your practice. I talk about patient with conditions like RLS, Parasomnia, narcolepsy, eating and movement disorders etc. that helps your morale but hurts your pocket since you will order less polysomnograms. Aslo if you mange to get a lot of doctors order your tests from their office that can be helpful but a bit frustrating when you read the test.
Another thing is that if you find a way not to have “non physicians” as co-owners of your center – I did not find that way yet, then your income will be way higher. I know some successful people who make numbers comparable to ortho but I think that should not be the comparison because there is only one life and we should do the thing that we like as Micheal Rack said. I also think the business of medicine is an extremely important part of your job … if you do not like it go be an employee but you will be hearing how bad you are for the rest of your life. I was thinking this aspect is a bit exagerated in Micheals notes but remember he is studying MBA now and directing a medical business …. What did you expect?
Another issue about sleep medicine is that since it is conected to a big revenue, there is a lot of local politics with other doctors and hospitals involved in the practice that will be ongoing and inate to the business model that you have.
If somebody likes to think about whats wrong with the patient in depth, make difficult differential diagnosis, has a technological savey and does not mind spending several hours in front of a computer in each week then sleep medicine will be very rewarding to practice. It will provide you with a lush lifestyle (ofcourse talking about physicians) and has a good income.

By the way all sleep specialists agree that for most of the people PSG is really important test to be done and other tests if done are just as good as they get – maybe poor boy version of the real thing, and I am sure as somebody in the field of medicine you know that couple of articles are not enough. Maybe in few more years we know more but most of the people thing as Dr. Rack said just for the minority of the people who can not come to the sleep lab it is a good thing to do home monitoring. It is almost the same as saying D-Dimer can replace the CT of chest to diagnose PE … well yes maybe in a minority of the cases we settle down with just a normal D-Dimer. The home monitoring is being pushed by the ENT/Head and neck physicians to get rid of sending the patient to the sleep lab before they do some surgeries that are mainly not effective … look at Jan issue of sleep medicine journal for the meta-analysis … do not listen to them !!! just joking

By: Ambar

Ambar — Thu, 13 Mar 2008 19:17:28 +0000

Thanks Doc for the honest replies. It is really helpful to hear it as it is. As an aspiring med school student, I needed to know the facts. I appreciate your insight.

By: Phaedrus

Phaedrus — Tue, 12 Feb 2008 16:10:31 +0000

STOP THE PRESSES!

It’s shocking to see such honesty in an ‘official’ interview with a doctor. Dr. Rack, I hear you, and I appreciate what you’re saying. All good advice. This is the type of stuff veteran docs will tell you in private, but even they usually clamp down in ‘on the record’ talks if the topics of money or the business of medicine arise.

Just because we’re young idealists who want to save the world, doesn’t mean we won’t one day have a family, mortgage, and a need to actually pay off some of this multi-hundred thousand dollar debt! Further, Private Practice is a business, even if it’s essentially a non-profit endeavor for the modern socialist med student. A little money and business education go a long way in dealing with these problems.

Finally, there’s absolutely nothing wrong with insisting on adequate financial compensation for the 35 years of blood, sweat, and tears it takes to become a physician. If ALL I wanted was to serve the needy, I would have become a social worker/activist – THOSE are the people who affect large numbers of lives.

Thanks for the great insight, Dr. Rack, and good luck to you and your practice. I respect the ‘I’m no wage slave’ notion, and was very proud to have escaped wage slavery myself!

By: JJ

JJ — Mon, 11 Feb 2008 14:41:20 +0000

I am a psychiatrist and finds my work to be fascinating. I thought about med-psych combined residency for a while but then decided that psychiatry is a much better fit (medicine and many aspects of it are quite repetitive). However, pure outpt psychopharmacologic appointments that last 10-15 minutes each can be quite mechanical/boring as well. That’s why it is imperative to mix it up with interesting psychotherapy cases and some inpatient psychiatry work.

Why do people come up with the term “ROAD to success” = Radiology, opthalmology, anesthesiology and dermatology? Because medical students think about money a lot. That’s the reality of things and that’s how our society encouarges. It is ok for premeds to get 4.0 GPA and feel good about themselves, but it is not good for doctors to make $500k and feel good about themselves? After all, you are judged by your grades when you are in school. When you graduate, well, you are judged by money and power. The higher the better! Same concept. Why do politicians want to climb up power structure? After all, the higher they climb, they further away they are from “the people” who elected them and need their help.

If I were not in medicine, I would be in mutual fund/money management as well. It is just such a fascinating field. I am talking about “investing,” not “speculating.” Knowing the companies well, dissecting them and understanding investors’ psychology are all fun things to do. At the end of day, losing millions of dollars for your client will piss him/her off but unless you embezzle their funds, you are very very unlikely to get sued (not like doctors nowadays).

By: Sarah M. Lawrence

Sarah M. Lawrence — Thu, 07 Feb 2008 06:18:31 +0000

Thank you Dr. Rack, for doing the interview and for coming here to answer questions and interact with students. Your time and thoughtfulness is appreciated!

By: bert blanchard

bert blanchard — Thu, 07 Feb 2008 00:46:10 +0000

is a wholly owned by physician sleep lab also considered an IDTF and if so, is there a category for office based sleep centers other than hospital based?

By: N.P.

N.P. — Tue, 05 Feb 2008 23:20:29 +0000

Now that was some passion. Thank you so very much for your responses in your comments. This was very helpful and will give me some insight for my future. Those comments were very interesting to read. Thanks again and best of luck in your practice.

By: LM

LM — Tue, 05 Feb 2008 21:01:33 +0000

I appreciate Dr. Rack’s highly informative and realistic perspective on his career. Finances and compensation are issues that every physician needs to consider, beyond simply the blind idealism that a lot of pre-meds display.

By: $$$$

$$$$ — Tue, 05 Feb 2008 04:31:29 +0000

i think i was wrong for implying that dr rack was ‘in it for the money.’

as a student, though, i def entered the game an idealist and am day-by-day being frustrated by reality. i think there may be something to the fact that we future MD’s are not good at business dealings. maybe it underscores the fact that medicine, in principle, should be a field where idealists can thrive, since after all it attracts so many of them. ok, maybe that sounds loopy.

i am only coming from houston, tx, the home of the ‘largest medical center in the world,’ the texas medical center. sure its nice, but you can bet your ass the closest anyone without insurance is going to get to MD anderson is the shit-end of the medical center, the county hospital. the idealist in me cries out against what MBA style medicine is doing, the inequality its creating, etc.

but, nevertheless, i believe i was wrong for implying that about dr ruck, and i offer an anonymous online apology and rescind my anonymous online critique. clearly, he isnt one of the folks raking it in and living lavishly without regard for his patients. sorry.

By: Ron Bennett

Ron Bennett — Mon, 04 Feb 2008 19:26:24 +0000

thanks for the honesty. Many of the dr. I speak to wish they had done something in business-not for money, but to have a more family oriented lifestyle. 60 hrs a week is the norm and many have call for the majority of their careers. as Dr. Rack stated wagers make good money, but you answer to someone else. I personally left business to go into medicine. Money is very important to meeting the daily needs of life. Dr. Rack simply is helping many of you who may have only worked as TA’s or tutors set some priorities before you purchase the $500k home right away.