Saturday, November 24, 2012

Are Doctors Rich?

A buddy of mine sent along an interesting link by a physician named Ben Brown that makes an argument that doctors actually aren't all that well off.   Salaries are down.  Education costs can exceed $300,000 over the course of college, medical school, and residency.  By the time you take that first job, you're on the wrong side of 30 and Wells Fargo is demanding $1800 a month for all your student loans.  It's a topic I've covered many times before.  If you are looking to make a killing in the world, to retire to some beach in the Caribbean at age 55, then medicine is not the career path for you. 

It didn't always used to be this way.  Medicine once was a very lucrative career tract.  All preening mothers wanted their little boys to grow up to be a doctor.  It was a ticket to elite status, country clubs, and three week summer vacations in Italy.  Such ideas are laughable now.  Mothers prod their sons to go into investment banking or become professional athletes nowadays.  Why spend 30 years in school and training just so you can be an employee for a giant health care conglomerate that may or may not renew your contract on a year to year basis? 

I try not to get too concerned with salary or compensation.  I enjoy what I do.  I earn enough not to have to worry about when the next paycheck is coming.  I can afford to do extra little things to help loved ones/family members.  But the question raised is an interesting one: namely, what ought a physician to make?  What would be a just income for a doctor, factoring in length of training, the social good he/she provides, and the risks he/she takes on by operating and/or doling out medical advice. 

Some people worship at the altar of The Market.  We are paid exactly what we deserve, to the extent that it is commensurate with free market principles of supply and demand.  It's easy to bitch about left handed late inning relievers who sign contracts for millions of dollars a year but, in the context of the amount of money that MLB generates via billion dollar television contracts and lucrative stadium/concession deals, then it seems eminently reasonable.  I have a hard time trying to ram the medical model into such a cold, purely numbers-oriented mode of thinking.  Putting a price on one's health and even one's life, is inherently a salacious prospect.  A trauma doc who saves a young gunshot victim at 2 in the morning or a cardiologist who opens up  a blocked coronary on a 55 year old with 4 kids and 7 grandkids are paid a set fee according to negotiated reimbursement schedules.  What could they potentially earn for such life saving interventions?  What do they deserve?  20 grand?  A million bucks?  The deed to the patient's house?  It's like something out of some futuristic dystopian Phillip K. Dick story.

The years I have spent in medicine have altered my foundational thinking in many regards.  On the topic of remuneration, I have come to the undeniable conclusion that practitioners of medicine cannot be driven primarily by the desire to optimize personal wealth.  Hospitals and healthcare conglomerates do not fall under such auspices.  Private corporations ("non profit" or otherwise) can opportunistically maximize profit all they want.  Ethically, doctors cannot play on the same field of supply/demand economics.  Otherwise the entire profession is demeaned, desecrated.  Specifically, within the context of the present private health insurance/Medicare scheme, it is unethical to render medical service for the express intent of maximizing profit.  The exception to this would be a physician who operates outside the present insurance/Medicare paradigm and runs a boutique practice whereby wealthier clientele pay pre-arranged sums above the reimbursement schedules determined by Kaiser and/or Medicaid.  Perhaps there would be a few who are able to exploit this loophole either through brilliant self-promotion or reputation.  But for the majority of practicing physicians, wealth will remain a pipe dream.

At the same time, the pendulum cannot swing too far away from physician earning potential.  Student loans are crushing.  The cost of living is higher.  Employment, along with all its downsides, has become the default option for younger graduating residents.  Doctors should not be disrespected.  Most physicians I know have committed their lives to the concept of "helping others".  Sacrifices were made along the way.  Deferred gratification was practiced at Taoist degrees.  The idea of devaluing a professional who spends 30 years training and hundreds of thousands of dollars on a career whose purpose is to heal the sick, assuage despair, and alleviate the pained should be just as unacceptable as the orthopedic surgeon who maintains his volume by doing hip replacements on demented 80 year olds.

 I am reimbursed less for a hernia repair now than surgeons were paid 15 years ago.  Colon surgery is cheaper now than it has ever been.  I recently replaced four tires on my car for about $800.  It took 90 minutes.  All the while I was thinking that those new tires were costing more than what I would get paid for the gallbladder surgery I had booked for the next day.  I mean, tires are important.  I get that.  I have two young kids I drive around.  But shit man, I've changed a few tires in my day.  Somewhere in all this bickering and heated rhetoric is a balanced and just solution.  Some ideas to chew on:

  • Transparency.  Nobody knows how much anything costs.  Third party payers (health insurance companies) eliminate all communication (other than co-pays) between consumer and provider.  The negotiations between insurance companies and giant health care conglomerates all occurs behind closed doors.  So if Giant Conglomerate makes a deal with Insurance Company that guarantees a higher payment for blood work in exchange for an increased volume of patients (something that happens all the time) then patients are left in the dark and will have no idea that a smaller lab company down the street can run CBC's and BMP's for half the cost.  And if Giant Conglomerate employs its physicians, then the gate is closed and there is no chance for competition to drive costs lower. 
  • Medical School Loans.  It now costs upwards o $250,000 to finance a medical degree.  And then you have to pay back all the interest.  So doctors are looking at being in the hole half a million dollars once they have completed residency and are looking for that first job.  This is insane, unjust, self-defeating.  An yet we go on and on about "doctor shortages" and "critically underserved areas" in this country.  Instead of addressing the driving force for why someone would rather be a super subspecialist in a procedure-oriented discipline rather than a family practice doc in Omaha, we look to take shortcuts---- i.e. trying to get mid level providers who take the place of physicians.  How about this:  Subsidize the education of those who agree to work in underserved areas.  Eliminate the third year of medical school.  Increase federal oversight of price gouging state medical schools with full audits of these publically subsidized institutions.  Loan forgiveness for certain specialties and certain geographic areas,
  • The Marketization of American Healthcare.  I have already described how such an outlook has no role for the practicing physician.  For the Hospitals and Healthcare Conglomerates and Big Pharm and Health Insurance Industries, there is no such ethical limitation.  The idea is to make money.  Lots of it.  We should not be surprised that health care is so expensive in this country given that healthcare is run, managed, and provided for by entities who are ontologically driven to maximize share holder positions.  A single payer would re-orient all such nefarious priorities. 
I have faith the general public will always acknowledge the special role that physicians play in the fabric of Life.  And I have faith that doctors will always be remunerated appropriately for their efforts, as long as we continue to practice ethically and selflessly.  We are not meant to be rich.  We shouldn't have to live paycheck to paycheck, however.  We shouldn't be paying back our own medical school loans while our eldest children are out searching for colleges to attend. We are generously rewarded with the privilege of intervening in the life of a stranger.  We are given a peek into the dark night of the soul of these men and women ambling into our offices and trusted to do the right thing.  We are the luckiest professionals on earth.  We are not to be taken for granted, to be devalued as a mere employee, a cog in the machine.  But we ought not to abuse our privileges either, as, unfortunately, it seems we did during the 70's and 80's.    

1 comment:

Paracelsus said...

A very insightful analysis. Valid not only for the US.