The following is a reader take by Stuart Sutton.
The U.S. Dept of Labor says that the number of people working 2nd jobs is the highest in 15 years. The motivation is, as would be expected, not just more income for enhancement of lifestyle, but a need for such to stay financially afloat.
There is often debate about whether doctors are paid a reasonable amount for their work. This is especially true with primary care, which, for many reasons has been less well reimbursed than other specialties.
But, are these claims of inadequate reimbursement legitimate? The decision by a doctor to add on hours of clinical work outside of his or her usual practice would seem a valid surrogate indicator for the adequacy of reimbursement.
In this discussion, I’m not concerned with the decisions of residents, fellows, or those who are just starting their practices when income is expected to be low and such work decisions are commonly encountered. Nor do I include the decision by a physician to simply expand their previous office hours in order to see more patients to enhance their income.
Rather, I am questioning whether the typical reimbursement for the work of a practicing primary care physician can be considered appropriate when that physician feels the need to add on work outside of regular office hours. This includes such activities as nursing home coverage, weekend hospitalist duty, or hours at an urgent care center. Such decisions equate to taking on a “second job” to make ends meet.
I could not locate any research on this issue with searches on PubMed. Anecdotally, neither I nor other moonlighting physicians to whom I spoke can recall any physician specialty participating in this activity other than primary care physicians.
Sermo, an online physician community had several prior discussions regarding moonlighting. Most of those discussions were populated by primary care physicians. A survey I conducted there confirmed that a majority of those who choose to moonlight (other than psychiatry where the activity is still psychiatric care in a non-office setting) are primary care physicians. (70% primary care with 30% divided among OB/GYN and medical & surgical sub-specialties). Although not an original query, among all the respondents, a quarter added in the answer that they “value their free time too much to moonlight.” This would seem to confirm the sense that such extra work is undesirable though sometimes necessary.
Primary care physicians may be more likely to moonlight because they, unlike other specialties, have more time available to do so. This seems unlikely, however, since adding on more office hours would be a far more efficient technique for enhancing income. Alternatively, primary care patients may only be likely to utilize the services of such physicians during limited hours of the week. This would leave other hours in which a physician could still work, but would have to seek other venues in which to earn additional income. Certainly, many moonlighting opportunities seem relatively well suited to the broad based skills of a primary care physician.
In either case, primary care physicians seem to be disproportionately in need of additional income sources. As with other workers, this need is driven by current financial stresses and not by a desire for additional lifestyle enhancement.
Ultimately, if any sympathy is elicited by tales of average Americans who have less time for their families because they need to work 2 or more jobs, then the same consideration ought to exist for moonlighting primary care physicians.
In this regard, the personal sacrifices are the same for the physician as they are for the Wal-Mart clerk.
Stuart Sutton is an Internal Medicine physician.
Related posts:
- Primary care-specialty income gap: It’s worse than we think
- The public devalues primary care
- Why this doctor left primary care
- The PCP-specialist income gap
- Make primary care more appealing
- How to fix the primary care shortage
- Males = specialists, females = primary care physicians
{ 14 comments }
I don’t think that moonlighting is the best way to measure the inadequacy of primary care salaries. For salaried positions, entry level compensation is going to be lower than for senior physicians. When I finished my Family Medicine residency 19 years ago, I had a lot of catching up to do, loans, starting a family, living like an adult. I took extra work, as did many of my friends. I have many friends who no longer moonlight, but have not had a salary increase in 10 – 15 years. They’re tired, they have kids and families and those things takes priority over money. They have adjusted by accepting the idea that discretionary income has decreased or vanished.
I started a private practice eight years ago, and at the beginning, I didn’t have enough patients to keep me busy or generate sufficient income, so I took another job. That seems reasonable, and is not a sign of inadequate pay.
One of the categories you excluded is a very good marker for the inadequacy of physician pay, which is doctors working longer hours in private practice. I now belong in this category, and as I said I am a Family Physician so I know about it first hand. Between 2006 and 2007 I had saw a 20% increaase in patient volume from 4,800 patients to 6,000 patients. My gross income went up almost not at all, while my expenses continued to rise. In order to maintain my income I have had to expand my hours and increase productivity. It’s not so I can buy another car. I don’t live luxuriously. My kids are in public school in Brooklyn, we have one car, and take two weeks of vacation a year on a budget. This mirrors the experience of my peers.
I spend 50 hours a week, no lunches, in direct contact with patients. I spend another 20 hours doing paper work during early mornings and weekends. I am on call 24/7. If someone like me expands their hours to make more money, the motivation has to be to adress a basic economic demand.
What other markers are there for inadequate pay for primary care. For one, no one wants to go into it. Training slots in Primary Care residencies are hard to fill. It’s not because medical students are selfish, money grubbing, uncaring snobs. It’s because they have debts, and know that if they want to have a life, they can’t afford to be primary care doctors.
Of the Primary Care doctors that are around, at least in Broolyn, few want to go into private practice. It used to be that private docs were the moneyed set of medicine. But not so any more in primary care. Putting together salary, work hours, and benefits, a salaried position is better than being your own boss.
A friend of mine did an Masters of Public Health program at Columbia University. As part of his work he did an economic comparison of Family Physicians to other proffessions and discovered that teachers in NYC were better off than he was. I don’t want to knock teachers, they too are an example of how we tend to under pay important service proffessions. The point is, is that almost everybody thinks teachers are under paid and struggling, so if doctors are doing worse the implication is obvious.
What about looking at what people are willing to pay when they spend their money out of network or for uncovered services. It’s usually 2 – 3 times what insurance companies pay. What about psychologists, whose fees are not covered by insurance. In NYC $140 is cheap, $200 is common. They have almost no over head, except rent, I don’t know any primary care docs, or too many other docs at all, making +/- $300K.
Financial trade magazines for doctors used to be about how to invest. Now they are all about how increase productivity and decrease over head.
Finally, the biggest reason that it is hard to guage the adequacy of physician compensation is that the source of money comes from reimbursement rates set by insurance companies, Medicare and Medicaid. Because doctors are prohibited by numerous legal restraints from organizing to negotiate their fees it’s hard to know what things would look like if there were a level playing field. The few large payers can simply set the fees and tell doctors to take it or leave it. As long as it looks like there are enough takers it looks like the rates are adequate. It is a pretty sad standard to set for the value of what physicians do to say to us, that as long as they haven’t driven us completely out of business or out of our minds that we are well paid. I think that the day is coming when, like that famous scene from Ntwork, that doctors are going to open their windows and scream, “I’ve had enough, and I’m not going to take it any more.” In fact, if I knew how to organize it, I would try to get it done tomorrow.
Charles Berk, MD
It was only a matter of time, but the “primary care physicians aren’t adequately reimbursed” topic has finally jumped the shark. I’m not saying that the premise of inadequate reimbursement is inherently incorrect – on the contrary, I agree with the general consensus on this site – but rather object to the completely outlandish analogies and unsubstantiated assertions that this particular author has put forth.
“As with other workers, this need is driven by current financial stresses and not by a desire for additional lifestyle enhancement.”
Where in your post do you substantiate this claim? Whose to say doctors don’t moonlight so they can take that extra vacation or afford the the slightly larger television. Your post never once offers any evidence with regard to motivation.
“In this regard, the personal sacrifices are the same for the physician as they are for the Wal-Mart clerk.”
Congratulations! You just insulted tens of millions of Americans who actually endure financial hardship on a daily basis in this current difficult economic environment! (Don’t worry, they’re not reading this – they can’t afford computers). The insensitivity (and ignorance) is mind-blowing. Personal sacrifice? That concept is meaningless to an individual who works a second job for minimum wage. They’re more concerned with putting food on the table then any personal freedom they may be sacrificing. Do you struggle with heating bills? Paying for a tank of gas? Do you have nothing saved for your children’s college? This is the situation facing millions and millions of American’s every day.
The problem is not true economic hardship, but rather a failure to meet expectations. Take the first commenter. Forget the fact that he chose to live in one of the most expensive places on earth and practice a speciality which is not highly valued in that particular region of the country. His kids go to public school! Oh the horror! He drives one car (in NYC where a car is a luxury)! He only takes one modest two week vacation a year! Guess what folks. This is the life your average mild-mannered middle class professional. The problem is that nobody who shelled out the money to go to medical school expected to be average, or even middle class. And speaking of debt, your $100-150,000 salary is far above the average American, many of whom also have educational debt including debt from undergraduate education.
Primary Care physicians are undervalued and underpaid. But there’s no need to devalue the struggles of millions of Americans by pretending you’re in the same boat. You’re not. You’re not even in the boat right next to them. In fact, you’re not even on the same body of water.
4:57, you should take a few of your own suggestions in a way of self improvement.
>>”Don’t worry, they’re not reading this – they can’t afford computers)”
Really? Even with the employee’s discount from Wal-Mart? Where is your proof of that?
>>”. . . tens of millions . . . “
And your source for this is? Hyperbole and of course, untrue.
Got something against chain retail, or are all those supposedly po’ folks working for Wal-Mart your favorite straw man?
>>”. They’re more concerned with putting food on the table then any personal freedom they may be sacrificing.” Now you’re sure of that? Couldn’t be they are working up an investment stake to start a small business of their own, maybe? Or do your own silly-ass presumptions about the working class preclude your considering that? Naw, they have to be poor and dumb, otherwise what could you bloviate about?
Hey, you run into Michael Moore lately? How’s he doin’?
Mike’s just great. He says hello
I never said dumb. You did. That says a lot about YOUR presumptions. Your other comments were humorous though, I’ll give you that.
Oh yea, a couple of other things…
I checked and you were right… I exaggerated about the tens of millions working class people in this country. It’s more like ten or twenty THOUSAND. My bad. And, as it turns out, most ARE building that nest egg with their second job, though it’s not to start their own business. Most want to retire by 50.
>>”Don’t worry, they’re not reading this – they can’t afford computers)”
“Really? Even with the employee’s discount from Wal-Mart? Where is your proof of that?”
Well lets see here the average worker at Wal-Mart makes about 7.00 dollars an hour. Now it is also Wal-marts policy to keep as many workers as possible working part time, rather than pay them benefits. so their full time hrs start at 32 hours per week, which means most employees get scheduled 31.5 hrs per work and will be sent home early on Friday if that average has been exceeded, even if they were doing the company a favor by working over when someone called in.
But, just for the hell of it lets “pretend” they all work 40 hrs per work for 48 weeks per year at 7.00 per hour.
OMG, brace yourself, because their full time employees have now made some where around 13K a year. Now if they are making a house payment or paying rent, raising a couple kids, putting gasoline in a car and trying to pay utility bills, its quite easy to see they have more than enough money left to buy a computer. Or, maybe a bit of common sense might tell you otherwise?
Imagine if both grown ups in one family are both working full time at Wal-Mart? Goodness, they are making some where around 26K combined total yearly income. They ought to be damn ashamed of themselves for making that much money. Especially when you do a comparison and consider what they are making with what the poor physicians have to settle for. We are SO sorry for you!
“Ultimately, if any sympathy is elicited by tales of average Americans who have less time for their families because they need to work 2 or more jobs, then the same consideration ought to exist for moonlighting primary care physicians.”
I think I am going to throw up with disgust and shame.
I earn near the bottom of the average PCP–and that is a big jump this year–I have been below the usual numbers by about 20% for several years.
And I am not whining. I am grateful that I had the chance to get a medical liscense and took it. Sure, I worked and paid for it, but I didn’t make myself and could have been born without the health or intelligience to do so, or my family might have needed my support in those years or a dozen other things out of my control might have thwarted me.
And I have had no problem living on 80% of the average of PCP’s. No problem at all. And I paid off my student loans and completely paid off my house in 5 years while I was at it. The loans weren’t a lot–that is true. My wife doesn’t work and yess we have kids. They went to private school part of the time and one is in an expensive private college.
It isn’t hard at all, I feel rich, and am flat out embarrassed to see colleges grubbing for sympathy and comparing themselves to semi-skilled retail workers.
The problem that I see with docs who make less than 200,000 a year is that live too large–spend too much money. They feel entitled to certain things that they just don’t need and sometimes can’t afford. I didn’t buy in the neighborhood they bought into.
I have no problem living on several times what Walmart clerks live on and don’t much respect for someone who does and no respect for someone who whines about it. Clearly someone who has never been poor and has no idea whatsoever. Maybe that is the problem. I grew up poor–really poor and even pinching pennies in medical school never seemed a burden or anything to complain about. Any doctor I know, given the grocery budget of the average non-college graduate to live on for a week would run out of food by Tuesday.
For people who moonlight to buy the luxuries to which they feel entitled to compare their “struggles” to people who moonlight to keep the family in a home and out of malnutrition is ridiculous and disgusting.
I don’t know if you want to call it “moonlighting”, but it helps independent primary care doctors to sort of even out and diversify their revenue streams with various side jobs. Medical director of places that need a physicians skill and judgment for certain supervisory things. Nursing homes and various care homes. Sometimes businesses that need physical exams on new hires. Psych facilities that need a general physician for the medical issues that follow along with the psych problems.
I’ve known some docs who hold contracts with the local health department or the local jail. Sidelines to full-time office medical practice. Part-time work that’s administrative and once-in-a-while physician backup of the nurses and other personnel working there full-time.
Having diverse revenue streams gives you the ability to say no to an insurance plan that gives you a hard time. You can survive the loss of revenue. You can enlist your patients affected, they can write the insurance plan, and this sometimes gets the insurance plan to to negotiating table. Or just plain walk away if they won’t budge.
I knew one big internal medicine practice that did a big portion of their business with one 800-lb gorilla of a regional HMO. Then the HMO went bankrupt, and the economic shock really hurt the medical practice. A lot of layoffs of nursing personnel and even junior physicians.
So I for one don’t like to see any particular insurance become dominant in my practice.
physicians live poor for so long, through undergraduate like many others of course, but continuing through medical school and postgraduate training. They do tend to start living beyond their means when the income really flows.
If more physicians lived within their means, they would be in a better position to say “NO” when faced with…..well, a lot of the things blogged here and elsewhere. And just walk away.
The envious and presumed rightous have had their say above.
But there is something to say about unmet expectations. I don’t think there is any longer course of education nor a more expensive one, nor one where the opportunity cost is higher than in medicine. If you compare comparably qualified students, the medical student–resident doctor is deferring key life purchases like a home, a retirement fund and savings for education far longer than any other college-educated person. Snide and envious people will remark that they can go live in the kinds of houses their patients do, and maybe they should, but nobody wants to count the ten years of not being able to buy even that house, never mind the lost opportunity at equity gains and other forms of wealth accumulation most people take for granted. Nobody wants to consider the costs of accumulated student debt, or of capitalized unpaid interest or of lost opportunities to earn a salary large enough to contribute early in one’s working life to a retirement fund, when those contributions can do the most earning.
Trucking out stories of others’ hardships adds nothing to this discussion–it is irrelevant.
If we as a nation expect doctors to be available to us on terms of entrepreneurship–and we do–then we shouldn’t be surprised to find little service available where the means aren’t there to pay the costs of service, and that means no less than the costs of my forgone opportunities.
If no place wishes to recognize the value of those sacrifices, then we rightly deserve to be a nation with a shortage of doctors, with all that follows from that.
“Trucking out stories of others’ hardships adds nothing to this discussion–it is irrelevant.”
You’re absolutely right – though I assume you are referring to the comments. But it was the original poster who introduced the irrelevant comparison in the first place. That’s where he went wrong and alienated some readers. You can very effectively make the argument that primary physicians are underpaid and even discuss moonlighting in this context without resorting to these outlandish and, frankly, insulting analogies.
“If no place wishes to recognize the value of those sacrifices, then we rightly deserve to be a nation with a shortage of doctors, with all that follows from that.”
You’re paid better than any profession in the world, by 50%. What else do you want? Statues?
In my state’s capitol city, the local business magazine did a review of all the houses that sold for over $1 million, and who lived in them and what they did. The single largest profession? Doctors by a landslide. Most employed at the local university hospital.
In America we get compensated by money, and you are compensated better than 99.9% of the world on average. If you can’t manage your money, that’s your fault.
>>”You’re paid better than any profession in the world, by 50%. What else do you want? Statues?”
How about a citation for starters. Nothing like throwing around dramatic numbers with nothing to back them up. Can you?
Any profession? MLB? Investment banking? Commodities trading? Dentistry? Commercial banking? Actuarial consulting?
Big houses in your hometown? So what. That seems to be the limits of many people’s experience: the guy with a big house in this little town, he’s the doctor. (We forget about the guy next door that owns a couple of McDonald’s stores, or the dentist across the street, or the senior VP from the bank, or the real estate company owner, or the owner of the quick-marts.)
>>”you are compensated better than 99.9% of the world on average.”
More unsubstantiated garbage numbers.
So I should just be grateful and shut up, eh? I think not.
I also paid more for the privilege of practicing medicine than 99.99% of the world–to paraphrase you. So your point is exactly what, that I shouldn’t be well compensated? That I shouldn’t seek a fair return on all my investment? You spew tough talk about managing money–with your fake numbers and all– well, seeking and getting a fair and reasonable ROI is just that, or is that kind of money management not the thing you approve of?
“How about a citation for starters. Nothing like throwing around dramatic numbers with nothing to back them up. Can you?”
Department of Labor stats. Go to their website.
“Big houses in your hometown? So what.”
Actually, that’s just an example. I’m not citing it as statistical proof. Only a physician takes anecdotal evidence and advocates policy changes like that.
“More unsubstantiated garbage numbers.”
Again, I’m not a physician. I don’t just take numbers that an insurer tells me and swallow them whole and regurgitate them. None of my numbers are fake. The world’s average income is $7,000 per year. If you make the AVERAGE US physician salary of $150,000 per year you are in the top .33% of the world:
http://globalrichlist.com/
http://hypertextbook.com/facts/2006/MateNagy.shtml
My point is not that you shouldn’t be well compensated, I think you should. You work very hard at a very demanding job. My point is simply that other people work very hard at very demanding jobs and get paid far less and they don’t have the financial opportunities to set themselves up for life if they manage their money correctly like you do. Their jobs physically break their bodies down, and they will never have high enough earnings to retire early, no matter how well they manage because so much of their income is eaten up by basic necessities. When gas doubles, it has a MAJOR effect on their lifestyle.
Appreciate what you have. If you want to modify your reimbursement scheme and make more, great. I encourage you to do it. But don’t incessantly whine about how bad you have it. Because you’re doing far, far better than the vast majority of the world.
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