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April 20, 2005
Why Medicine Sucks in '96*
In a post attacking nationalized health care, Sebastian Holsclaw says something that's simply wrong:
It takes a lot of work to become a doctor. It takes a lot of time and effort. Few people are going to put the time in if they aren't well compensated.
It just ain't true. In France, physicians make about $55,000 (US dollars), around 1/3rd what American doctors make. So is there an enormous doctor shortage? Not in the least. France has 3.3 practicing physicians per 1,000 residents, America has 2.4.
This is a common and, frankly, inexplicable oversight opponents of nationalized health care make. So let's say it slow: money is not the sole factor dictating occupational choices. Enormous swarms of folks sign up for endless years of education in order to make paltry sums in academia. I'm heading to Washington to -- hopefully! -- make an absurdly low wage as a writer. And you know what? I don't expect that I'll ever make much money in the profession. People go work for NGO's, in politics, as social workers, and on and on, none of it for the money. Lifestyle, internal satisfaction, passion for the profession, and a host of other non-monetary factors weigh heavily on occupational choice.
If doctors were only entering the field for the money, that'd be a shame. But they're not. In fact, many of them are leaving it due to work conditions. Considering the number who complain about the total hell that the medical profession has turned into, I'd guess a pretty high percentage would take a paycut in exchange for an end to haggling with insurance companies and filling out forms (the average Canadian doctor's office spends two hours a week on billing, the average American office spends 30). It's not all about money and we shouldn't assume that just because we pay doctors princely sums, that doing so is an immutable law of sustaining a professional medical class. It just isn't so.
* If you know the song, you know the answer.
April 20, 2005 | Permalink
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Comments
The money baby! DJ Shadow, muh fucka!
Posted by: josephleon | Apr 20, 2005 4:26:55 PM
I believe the proper response to this heretical reasoning is to point out that anyone who's motivated by anything other than income maximization is a loser by definition. By extension, only a fool would want to treated by a doctor who isn't in it for the money -- right?
Posted by: sglover | Apr 20, 2005 4:35:33 PM
Do you know what the relative cost of becoming a doctor in France compared to the United States? France, as I would guess is the case, may subsidize the cost of education. This could be the causality for a higher per capita count of doctors.
Posted by: Gill Potter | Apr 20, 2005 4:49:23 PM
I found when I was in France, that going to university was actually encouraged and supported by the government (as opposed to the United States). Also, when you don't have to worry about doctor's bills and the cost of health insurance policies, you will find some of your cash is freed up for other things like, say, a college education for your children.
Posted by: Dianev. | Apr 20, 2005 5:14:20 PM
I found when I was in France, that going to university was actually encouraged and supported by the government (as opposed to the United States).
Huh? Where does that come from?
Posted by: Ugh | Apr 20, 2005 5:28:07 PM
Milton Friedman has consistently argued something that you and I can agree with him on - that the limitations on the number of eager potential students getting into Med school is effectively making a monopoly situation. More Med school admissions and doctor salaries will fall accordingly.
Posted by: pgl | Apr 20, 2005 5:30:33 PM
Gill - we subsidize the education of economists so why not doctors. But then Dr. Friedman would argue your analysis is incomplete - we also artificially limit the number of folks getting into Med school.
Posted by: pgl | Apr 20, 2005 5:32:20 PM
One thing I've always wondered about, but never researched in any direction, is the effect of the AMA in creating an artificial doctor shortage. Do other countries do something like this? Is it a significant contributor to why American doctors are so expensive?
Posted by: Allen K. | Apr 20, 2005 5:32:40 PM
I dont know about AMA-like orgs in other countries, but the AMA sure as hell contributes to the artificial doctor shortage. They have a large self-interest in keeping wages high, labor scarce, and also the intense professionalization and mystification of medicine. That and a lobbying effort that would blow your mind.
Posted by: Kate | Apr 20, 2005 6:34:26 PM
Great post, Ezra. I'm a late-comer to your blog, and i'm enjoying the health care related posts greatly (among the other posts) as this is a passion and interest of mine.
Yes, the AMA has kept the numbers of admissions into med schools down, and for the purpose stated in this post and comments. There are tons of possible future physicians who would LOVE to become physicians but are not allowed a chance. There are tons who would take a salary hit because they love what they do.
And yes, the role of the cost of medical education is sadly resulting in many current medical students choosing specialty fields because of the increase in salaries. We need more primary care docs, but with an average student debt of $120,000 coming out of med school, many students don't want the 100-200 thou salary that that would provide, and instead go for a residency in something like anesthesiology, which pays $300+ for less hours. To me, this is VERY sad.
And another result of fewer med school spots -- fewer graduating american medical students, and more "importation" of physicians from abroad for a lot of the primary care needs around the country. This brain drain is especially harmful to other countries' infrastructures (3/4 of all ghana-trained doctors come to the US or Canada). I'd call this stealing from other countries, in which good docs are even more needed (many fewer docs per 1000 population than here).
Posted by: Anjali | Apr 20, 2005 7:13:57 PM
And yes, the role of the cost of medical education is sadly resulting in many current medical students choosing specialty fields because of the increase in salaries. We need more primary care docs, but with an average student debt of $120,000 coming out of med school, many students don't want the 100-200 thou salary that that would provide, and instead go for a residency in something like anesthesiology, which pays $300+ for less hours. To me, this is VERY sad.
The problem is the crippling debt that young doctors graduate with -- frankly, if I'd graduated with an AVERAGE of $120,000 in student loans, I'd probably take the highest-salary job I could find to get those suckers paid off as soon as possible.
People shouldn't have to graduate with crippling debt. I think doctors are important enough that the government should subsidize at least some specialties -- say, they'll forgive half or three-quarters of your debt if you go into primary care. That way, students could make a rational decision between less upfront salary plus less indebtedness or higher salary with higher indebtedness.
Posted by: Mnemosyne | Apr 21, 2005 12:48:29 AM
Actually, the federal government and the state governments subsidize the cost of educating an MD to the tune of about $500K. The remainder is the student's responsibility. It's expensive to train docs. Oral Roberts University tried to start a medical school, but shut it down because of the cost (also it's hard to train physicians with out using science and biology). There are now multiple for-profit, off-shore med schools including one virtual medical school on-line. Americans also attend medical school in Spanish in Mexico, Italian in Italy, and a new English language school in Poland. They are quite expensive schools.
The AMA is a lobbying group and about a third of physicians (mostly older) belong to it. They are noisy, but wield a lot less power than everyone seems to think.
Posted by: J Bean | Apr 21, 2005 2:37:46 AM
An average debt of $120,000 coming out of med school?
By the time I finished med school in Holland, I had raked up some $2500 in debt. And that was mostly because Amsterdam is a nice place and I ought to have graduated sooner.
It seems to me that the risk associated with that much debt at a young age is only bearable if you've got parents rich enough to bail you out if anything happens, and only if the job you're going to get after graduation is garantueed to pay a shitload of money. So if Milton Friedman wants more and cheaper doctors, he's going to have to address the cost of med school. How is mr. free market going to do that?
Posted by: jasper emmering | Apr 21, 2005 2:46:42 AM
Two points:
1) DJ Shadow may be God
2) One of my best friends is an ER resident. He told me a story about six months ago at SF General, where he was caffeining up for the sixth time in a 30 hour shift, and one of his co-workers, a second-year resident, was talking about how he fell asleep on shift.
With his hand on someone's heart.
Ribcage cracked, chest open, hand on heart.
Um, yeah. Our medical system rules.
Posted by: Dan | Apr 21, 2005 3:16:13 AM
What get me is how doctors believe in training people until they're in major sleep deprivation, even though all studies that I'm aware of show that SD makes learning less effective.
Posted by: The Dark Avenger | Apr 21, 2005 3:33:28 AM
I'm dashing off to class myself so I don't have time to write a thoughtful reponse to the content of the post, but I had to mention that DJ Shadow is fantastic beyond description.
Posted by: Ben | Apr 21, 2005 10:23:19 AM
Plus, if doctor salaries were lower, the profession would attract more people who really WANT to be doctors, not just make a lot of dough. When I was in college in the early 1980s everyone was pre-law or pre-med -- those were the moneymaking majors. Investment banking wasn't on the scene yet.
My dad is a doctor. I've seen him and my mother lose entire Saturday afternoons filling out Blue Cross forms. What a waste.
I'm certain that a lot of present doctors would accept less money in return for lower debt, and most importantly, less harassment from insurers. Doctors have to train for many years, are groomed to be smart, knowledgable, decisive -and then what do we do? We make their decisions subject to veto from some HMO pinhead hundreds of miles away. Again - what a waste.
More physician autonomy in exchange for less wealth - that's the way to go.
Posted by: Lisa | Apr 21, 2005 11:11:34 AM
The point that several other commenters have made about med school bills is important. If we lower the amount of debt prospective physicians have to take on, then presumably at least some of them won't feel the need to make large amounts of money. Another relevant point here is that the American system has lagged behind the rest of the West in using intermediate providers, i.e. physician assistants and nurse practitioners. These providers go to school for only 1-3 years post-college, so their training isn't nearly as expensive, they make a middle- to upper-middle class income, and they can perform many health-care tasks that historically have been reserved to physicians. We're starting to catch up, but we need to be putting far more emphasis and training and using intermediate providers. (Full disclosure: I'm due to graduate from a nurse-practitioner program in December.)
Posted by: Rebecca Allen, PhD | Apr 21, 2005 2:18:25 PM
I can appreciate all of the comments about Doctors being Doctors for reasons other then money (and thankfully that does happen), but in the world of professionals (Doctors, Lawyers, Accountants etc.) society in some ways has decided that these people are valued based on their compensation. The "seasoned" attorney bills more per hour than the "newbie" attorney, thus signifying that the person that is paid more has more perceived value. To compound this problem you have to take into account history. Historically, Doctors have been compensated well for what they do (or don't do). Many physicians will tell you that they were paid as much or more in 1990 as they are today (it would be hard to do the same work or more work and be paid less than what you used to be paid). In addition, they will tell you that they have more expenses to keep up with the technology and to stay our of the way of potential litigation.
Love the dialogue, but you you're making me feel old as I had no idea who DJ Shadow is or what he has done. Looked him up and it appears that he sells ringtones for phones. Seems odd many are willing to pay for ringtones for phones but balk at "paying" for their healthcare or their wellcare for that matter. It has always bafled me that we will pay to be entertained but not to have our healthcare matters taken care of in a sensible fashion. Oh well, the market is the market....
Posted by: Gunner | Apr 21, 2005 2:46:08 PM
I agree that there are certainly people who would still want to be doctors if salaries were lower. Certainly salary is not the only thing that drives choice of occupation. For instance, I could have gone to B-school or law school which would have taken fewer years out of my earning life and would have left me with a higher income. However, neither of those disciplines interested me as much as medicine, so I chose the lower income, worse hours, longer education route. Not everyone makes that decision. There is a shortage of nurses and math/science teachers in this country because women are less willing to work at the lower paying, lower prestige jobs now that other alternatives are available to us. That doesn't mean that no one chooses to make that compromise, but there is a clear effect.
I'm not arguing that docs aren't paid well. We are. However, it is not the munificent sum that everyone imagines. Compared to other professionals with similar levels of education, the compensation is good, but similar. I make 10K/year more than my PhD husband, but I work substantially longer and less appealing hours. I certainly don't make the $1M that many of you imagine.
Physician compensation was substantially reduced by HMOs. It now makes up about 10% of healthcare costs while insurance overhead is around a third. Arguing that MD pay should be cut is really pretty silly. It isn't a big enough part of the problem. French primary care MDs live a lifestyle that is approximately the same as mine (except, damn it, they get to live in France!) because cost of living and relative salaries are different. French nurses get paid less than Americans. French teachers get paid less than Americans. French lawyers get paid less than Americans. You get the picture.
Posted by: J Bean | Apr 21, 2005 3:54:25 PM
I didn't see anyone arguing for a MD pay cut. The idea was to reduce medical school debt for doctors, so pay wouldn't be as important, and doctors could survive better (have more perks due to less immediate debt) on primary care money(as ooposed to specialization).
Also J Bean, I believe that the AMA not only sets training standards, but allocates the number of medical school positions(allotments). I learned this from news and I believe AMA publication (maybe some other medical/medical student magazine...I lived with my friend who is in med school). Obviously there is federal money going in, but I was under the impression that essentially AMA controls the distribution(maybe not directly).
Posted by: Rambuncle | Apr 21, 2005 9:15:56 PM
I'd heard that malpractice insurance was much less in Canada. Combined with paperwork overload, maybe it's understandable they don't think of big bucks so much as bottom line and quality of life when considering the option of a move south.
Posted by: opit | Apr 21, 2005 11:43:16 PM
There's also admissions procedures to consider. I'm not solid on the facts here, but my understanding is that European medical schools take students directly out of high school and then weed out a number of them during a tough first two years. I'm sure that causes pressure, but I'd bet it's a helluva lot easier than the American system where a pre-med student has to maintain near perfect grades, recs, lab research, MCAT scores for four years of undergrad just to get a chance at a US med school.
Posted by: Jeff | Apr 22, 2005 10:10:53 AM
Fully agree with you. AMA is creating an artifical shortgae of doctors.
Posted by: George | Jan 7, 2007 11:21:32 AM
Love the AMA!!
Posted by: Doc | Jul 26, 2007 9:44:27 PM
