Why does society frown on doctors earning a reasonable living?

Recently, while jogging through my community, I had the pleasure of bumping into a former colleague and his brother who were out for their daily five mile walk.

Dr. G. had attended a local medical school, finished near the top of his class, and had gone on to do his internship and residency at the premier private hospital in Miami Beach, Florida. After completing his residency in internal medicine, and achieving Board Certification, he moved to Palm Beach County, Florida to practice.

He became the medical director of almost every skilled nursing home in the area.  No one wanted the job. The patients were elderly and in the last years of their life.

The bureaucratic rules meant he received hundreds of phone calls from the nursing staff at all hours of the day, every day. If a patient had indigestion and needed over the counter medication, they were required to page him. If a patient scraped themselves and needed a band aid and peroxide they were required to call him, all day and all night. The calls were so frequent most physicians would not cover his practice so that he could get a day off or take a few days vacation.  I met him for the first time while we were waiting to meet the Board of Directors of the local hospital on our first day of becoming staff members of the only hospital in the area at that time.

Over the years, my associate and I would take pity on the poor dedicated soul and agree to cover his practice so that he could take a break. It took at least two physicians to cover the practice and, frankly, by the second day the phone calls for minor ailments drove me crazy.

He practiced for 25 years then, due to some inherited money and good investments and savings, retired seven years ago. My only contact with him these days is meeting him and his brother on their walk. The conversation is always directed by him to the state of the practice of medicine. “How can you earn a living these days with all the cutbacks and regulations“, he would ask.  He would also inquire about health care reform and the sale of physician practices to the hospital and the health of colleagues he had practiced with.

On today’s walk he talked about a blog (website) he had discovered on line where physicians and patients discussed health care issues. He had read several articles about non physicians complaining about doctors earning money and charging a fee for the products and services they provide.  “What makes people think that doctors don’t have to earn a living to pay their bills as well as the next guy?”

Today’s walk was additionally special because it was the weekend of the NFL Divisional Playoff games. Dr. G. was a devout football fan. He bled Orange and Aqua for the Dolphins and Orange and Green for his Miami Hurricanes. As we walked he said,” I entered medical school in 1972 and completed my residency in 1979. It’s like there is this gap of seven years when I saw nothing and did nothing but study and learn medicine. I don’t remember who played in the Super Bowls let alone who won it. I don’t know who won the World Series.  I couldn’t tell you which movies won the Best Picture of the Year Award at the Oscars or who won the Tony for Best Musicals on Broadway?”

As we walked I thought about it too. Then I realized, that seven year period of time seemed as if someone had put a hold on my life as well. During that period, my friends from high school and college went on with their lives. They started businesses and other jobs. They married and started families. They travelled. They socialized.

I devoted seven years of my life to become the best doctor I could be. I studied and slept in-between 36 hour shifts on call with only seven or eight hours off at a time.  I had always considered my seven year gap a personal aberration but here was a colleague who experienced the same thing. I wondered about those physicians who had a ten or fifteen year post graduate experience before they got out in the world and re-joined the living. How did they survive?

Then Dr. G. said to me, “Imagine giving up seven or more years to learn and perfect your profession, helping others, and here we are in 2011 with patients complaining if you charge them a $25 co-pay or make a $2 profit by selling them a generic antibiotic they needed anyway”.

He has a valid point.  Our society doesn’t think twice about paying other professionals (I.e., attorneys, accountants, plumbers, electricians, etc.) a wage commensurate with their experience and expertise.  So, why then does our society, in general, have a negative perception of doctors earning a reasonable living commensurate with their education, experience and expertise?

Steven Reznick is an internal medicine physician and can be reached at Boca Raton Concierge Doctor.

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  • Maurice

    Reading this reaffirmed my previous decision to leave the practice of medicine.

  • http://www.thejourneytomd.com Jeremiah

    I think the dissatisfaction is displaced onto medical professionals.

    I am paying $500/mo for healthcare and each visit to my Primary Healthcare Provider is an additional $100+ by the time you total co-pay’s and what insurance doesn’t cover (if tests are ordered). So I am paying to much a month not to use it, but I am punished every time I do. None of this is the Dr.’s fault.

    But at the end of the day people only “SEE” providers. So the insurance companies are shielded from the majority of the displeasure. People love to shoot the messengers, regardless of how much of their life was sacrificed to master their craft.

    • buzzkillersmith

      Bingo. You can’t smack the insurance company because they are far away, but paying that much you sure feel like smacking somebody. The doc seems a reasonable target.

      • health insurance employee

        Really? ‘Cuz I feel pretty “smacked” – in the media anyway, what with politicians calling ALL health insurers “evil” (forgetting apparently that the majority of insurers are actually nonprofit and their CEOs do NOT make 8 or 9 figure salaries).

        I feel pretty smacked in the tweets and blogs that my job forces me to read because I’m monitoring social media to check on our company’s online reputation.

        I feel pretty smacked because it’s never the millions of claims processed a year that get reported breathlessly by TV anchors. It’s not the thousnds of members helped by our caring nurses and social workers who write letters to the editor (though they sometimes write very nice letters to us, which we can’t share because of HIPAA).

        I don’t say there aren’t problems — our folks actually take more calls from doctors than from patients, trying to figure out the Byzantine coverage system in which every group has custom-tailored it’s own policy (boy are they in for a rude shock with health care reform).

        With doctors in the family, I agree people have no concept of what it takes to get where you are, in time or money or passion. What complainers don’t realize is, if you all worked for what European doctors make, it would be only a negligible decrease in their health insurance premiums, because of the sheer amount of medical care being consumed. THAT’s what we need to focus on, somehow.

  • bob

    People complain about everyone’s salary. In general, the common perception I can see is that most people feel that every profession except their own makes too much money. And if someone works for a living, the salary which they consider virtually anyone else’s compensation to be “excessive” is their own + about 10%.

  • http://http//healthtrain.blogspot.com Gary Levin MD

    Spadly I have retired also due to the myriad complexiies. of malpractice policies, and bureaucracy. 40 years is enough. Will not give the State of California another nickel for an MD license.

    • buzzkillersmith

      40 years– wow. You have done your sentence. Thank you for your service.

  • Rich L

    Many of us went through the 7-10 years of hold on our lives with the expectation that we would be compensated once we entered practice. Young doctors today enter med school and training expecting to have a life outside the hospital during training but hopefully understanding that the compensation won’t be great once they get out of training. I really wonder if the current arrangement attracts a different kind of person to medicine (with a different level of commitment to patient care) and, if so, how it will affect medical care in the future.

  • Sheri

    I don’t understand the arguement that people don’t think twice about paying other professions the fees they are demanding. People do think twice about what they are paying professionals and often complain about how much they have to pay someone regardless of whether it is a doctor, attorney, plumber or any number of any other professions.

    The issue with how much doctors are paid has little to do with not wanting someone to make a good living, it has to do with the ability of the person to actually pay the bill. Even with insurance a major illness can wipe out a family’s finances for years to come and a minor injury could stress the budget for several months.

    The $25 copay people complain about is probably on top of the coinsurance for the medication, the deductible for the labs and another copay to follow up or see a specialist. It all adds up and becomes a burden people are finding harder and harder to bear, especially in this economy that has already stressed out people’s finances to the limit.

    • pj

      If only all (or even most) folks were as reasonable as you, Sheri.

      All too often I see and hear of people with million dollar houses and /or great benefits complain or resist paying their copay when it’s obvious they can afford it. Most Docs can testify about moms who “can’t” afford to pay for their kid’s visit who spend hundreds of $ monthly on their own hair, nails, shoes, etc.

      I suspect alot of it comes from the american “material mentality”- you don’t leave the doctor’s with a shiny new (toaster, hammer, shirt, bag of oranges, working sink etc.), so the need to pay for the service seems less important.

      Anyone agree?

      • horseshrink

        Had a biochemistry prof (http://en.wikipedia.org/wiki/Joseph_Nagyvary) who specialized in researching musical instruments from antiquity. He was able, cheaply, to replicate their sound very nearly. Concert violinists found the sound quality to be desirable, but Professor Nagyvary was unable to get these violins to sell until (at another’s recommendation), he cranked up the price.

        Lesson during psychotherapy training – patients more conscientiously use their therapist to some useful end when there is cost to the patient.

        Same for coaches/trainers. I pay a coach/trainer, you’d better believe I’m not going to let that money go to waste!

        It’s why ERs often require minimum payments from registrants who aren’t actively dying. If you aren’t willing to cough up five bucks for an ER visit, then it’s not important enough to you. Effectively sorts chafe from wheat.

        Lesson: People value more that for which they must pay.

        • health insurance employee

          And that’s the rationale behind the high-deductible health plans. Many of them have no-co-pay preventive coverage so people don’t skip visits where something might be diagnosed.

          The phrase is dated now, but I first heard more than 30 years ago that people want Cadillac care at Volkswagen prices…and that was in the days of $10 HMO co-pays. Nothing’s changed in that regard.

  • http://yahoo dixie gutierrez

    The fees charged every policy holder every month often go without notice. we pay to keep insurance just in case something happens, we are covered. this should more than cover the cost of the good dr.s wages and a fine living to go with that, why should we also pay a co-pay should be covered in the cost of a policy.

    • Vox Rusticus

      “his should more than cover the cost of the good dr.s wages and a fine living to go with that.”

      Except that it often doesn’t, no matter how much you wish is would. The co-payment is what the insurance deems worthy of being paid, except not by the insurance company. In some cases, it is nearly all of the charge. So assuming what the doctor gets from the insurer is both adequate and all that should be paid is nothing more than shrugging responsibility to pay, the very thing the worst of the worst insurance companies often do.

    • Primary Care Internist

      then get better insurance – there ARE policies that eliminate deductibles and copayments. Your lousy insurance paying me $30 and then making me charge you a $50 copay is what YOU signed onto, not me. I had absolutely no say when oxford suddenly bumped their copays for their “freedom” patients to $50 – not a peep from a provider relations rep or a letter to my practice.

      • Katie

        Hey there Primary Care Internist. Most people WOULD get better insurance if they could. Please remember the economy is terrible. Employers are passing along premium expenses to their underpaid, and increasingly overworked employees. Millions of people are unemployed. The plans available on the “market” are generally AWFUL. I realize you’re absurdly stressed and that it is terrible to hear people complain to you. But the market is not doing it’s job – insurance companies are not clamoring to serve customers (or doctors!). They’re doing a great job at hoarding the premiums and shafting you and the patient.

        • Primary Care Internist

          yes you are right Katie. What irks me, and i think many docs, is that many patients feel that we are somehow being GREEDY by collecting copayments from patients, who often feel “why should we also pay a co-pay…”.

          This is insulting, an affront to our worth, hard work, training, effort, education, etc., and represents a complete misunderstanding of the economics of a small office practice.

          • gzuckier

            Note that in fact, the somewhat frequent practice of providers forgiving their patients the copay (not just MDs; often physical therapists, etc. will make a point of charging no copays to get business) is a violation of their agreement with the insurer, for whom the copay is not just a way to offload some costs, but represents an attempt to get the patient to avoid unnecessary care; something he would get for free but doesn’t want to pay $10 or $30 or $50 for.

  • Vox Rusticus

    It doesn’t help that politicians and government confuse entitlement to government health insurance with entitlement to medical care. Nor does it help when Presidents glibly imply that medical care is free if one simply goes to an emergency room. Nor does the moral cowardice and dishonesty of congressmen who pass laws like EMTALA with no regard to the consequences of feeding the notion that emergency room care is something that cannot be refused, even for non-emergencies. (The canard of a “screening examination is a sham in the present medicolegal climate). People often resent being asked to pay for things they come to regard as entitlements. It doesn’t have to be logical, and it surely isn’t. Further, most people have never started a business of any kind, and so have little appreciation for enterprise risk; and fewer still have any understanding of what a decade spent in study and training beyond even a typical college graduate costs in terms of tuition, debt service and opportunity costs, including the dear but hard to enumerate value of forgone leisure,forgone pleasure and forgone or delayed life decisions. Really, as long as it isn’t about their lives and their choices, they never give it much thought (and resent ever being reminded of that when presented with a bill.)

    The USA has known nothing but rising prosperity coupled with rising expectations. That gentle upward curve has flattened. Our prosperity is over the last three decades illusory, nicer homes and cars, but less job security and less security in pensions and other less tangible assets.
    Debt rather than thrift has become the means for acquisition. In the face of deflating “wealth,” I believe the expression of resentment and entitlement will become ever more shrill.

    • imdoc

      Well said. Many “financially stressed” people right now are those with no prudence or discipline to save and manage money and provide for themselves.

    • L.

      WHY DOES SOCIETY FROWN ON (TEACHERS, STATE WORKERS, UNION WORKERS) EARNING A REASONABLE LIVING?

      “The USA has known nothing but rising prosperity coupled with rising expectations. That gentle upward curve has flattened. Our prosperity is over the last three decades illusory, nicer homes and cars, but less job security and less security in pensions and other less tangible assets.”

      I believe this to be true – I also believe the same sentiment applies to ALL professions – including doctors. So – as the middle class has shrunk, it’s wages buying less and less – why are doctors exempt from forgoing “entitlement.” The expectation seems to be that doctors are “entitled” to keep their level of income – but others are not.

      • Vox Rusticus

        Like any other business, medical practices see costs only increasing, and while wages may be deflating relative to other prices (like houses, pre-bubble-bursting), the wages of ancillary staff are increasing, while physician income has been relatively decreasing over the long term (while the cost barriers to professional qualification have increased at a rate significantly greater than inflation.) Doctors are seeing less income and have only been able to resist that trend by increasing productivity–coding up where possible and seeing more patients per day. But there is a limit to that. Moore’s “law” doesn’t apply to medicine any more than to any other highly skilled labor. By contrast, lawyers and architects have not been similarly squeezed.

        Doctors are not entitled to a particular income. And patients are not entitled to the convenient services of physicians (or for that matter, from anyone.) The idea that you will receive the same service as before, but for less money, does not hold, or at least not indefinitely. Practices are businesses and will close up and move, or just close up, period, when it no longer pays well enough to work in them.

        Whole continents have shortages of medical personnel and services not for lack of need, but for lack of means to pay for them. We aren’t special, just more fortunate, for now.

      • Primary Care Internist

        why are (TEACHERS, STATE WORKERS, UNION WORKERS) able to unionize but not doctors? why is collective negotation by docs illegal, but HIP and GHI can merge, and OXFORD and UNITED can merge.

        Also it takes at least 11 years to make doctors (4 undergrad, 4 med school, 3 residency). But in the same time someone of mediocre skill & intelligence can become a tenured public school teacher. or they can be half-FINISHED with a career as a cop.

        No, medicine is not like any other of these “professions”, not at all. If it’s so green on the other side, then go ahead & become a physician, it’s just so easy isn’t it?

        • L.

          The implication is that these professionals are not entitled to a fair wage and life of dignity, but doctors are? Really? You need to denigrate other professions to feel good about yourself? I know many teachers who work hours off the clock and use their own money to purchase school supplies. Doctors aren’t the only professionals who do uncompensated work.

          The argument that doctors are poor is a specious one. By all means, argue that your work is undervalued – it often is – but please spare the world your cries of poverty and abuse. Are we really supposed to feel sorry for you? More than the factory worker who can’t get a job with decent wages and benefits? Really?

          • Primary Care Internist

            What i am pointing out is that the commitment and talent level to becoming a physician is much much higher than a civil servant. And yet we actually have LESS rights than these groups, in terms of unionizing etc.

            Poor or rich, what does it matter? Aren’t we entitled to the same rights as you are? And yes it is abusive to REQUIRE physicians to work for free in some cases a la EMTALA. That is called slavery. look it up.

          • misstory

            Uhm, the difference is is that doctors don’t live off of tax payer funded wages or pensions. Teachers do. And if you are a teacher in CA, you can’t get fired period. Tenor is given after two years. The rest of their career is living off the tax payer teat and with zero or minimal contribution to self beneits. Doctors, on the other hand, live off of their own skill. BIG difference.

            It’s called the free market…look into it sometime.

          • elmo

            Agree with above.
            The simple fact is that public employees get awesome benefits that no one in the private sector can match. This is in addition to paying little or nothing towards these benefits that all private employees do have to pay, and at increasing amounts. I would take a pension plan over a 401 K in a heartbeat.

  • anonymous

    our society wants to view health care as a right. right = free. the fact that rights almost always refer to not being impeded from acting or thinking in a certain way, compared with being guaranteed the fruits of another’s labor without compensation – well, that doesn’t seem to register.

  • soloFP

    Copays of $30 for 2011 are just the tip of the iceberg. How about $2000 deductibles, insurance plans who charge copays and coinsurances on the same visit, and insurance plans that charge $2.50 a claim as a maintenance fee. A popular local plan charge me $250 a month just to process my claims, based on my number of claims each month. The plans represents about 10% of my patients. How about prior auths for meds, CTs, MRIs, PT, and other services, that are expected to be done for free? How about all the FMLA, disability, handicap sticker forms, and other “free” paperwork? How about all the middle of the night calls from patients, nursing homes, and hospitals, that are all done for free but still cary liability?

    • Vox Rusticus

      Why would you accept a plan that charged you a monthly “fee” for processing claims. I would cancel that contract no matter how “popular” the plan. Same with any plan that sought to charge a “maintenance fee.” If you go along with those kinds of abusive practices, you really are enabling the bad behavior. And as far as non-clinical administrative work like FMLA forms, attaching fees to those will quickly bring the volume of requests to a more reasonable level. I don’t waste my time with filling out disability forms when I think there is nothing supporting the claim.

    • health insurance employee

      Are you willing to forego fee-for-service payment model to get reimbursed for overall time/value? Be part of the solution! You should be paid for these services. Help your professional associations figure out how to get it done.

  • ManAlive

    At age 57, I’ve come to realize that a career as a public school teacher around here would have been more lucrative than my career in family practice.
    If Christmas cookies were dollars, I’d be rich.

  • Matt

    Other professionals’ billing is pretty straightforward, and you’re buying their time. With physicians, it’s never clear what you’re buying nor what the cost is, so that’s a poor comparison.

    Another reason people might get down on physicians’ earning a high income is that physicians are forever bitching about their expenses.

    • http://fertilityfile.com IVF-MD

      I completely agree that a prospective patient doing his due diligence to compare costs ahead of time runs into a frustrating blockade of obstacles and vague information. There are at least three reasons.

      ONE, there is little incentive for doctors to try and report clear price information when they are not paid by the patient, but rather by some third party. Contrast the advertisements for refractive surgery and for breast augmentation. You get a banner headline with a concrete price. Then you can contact the practice for a detailed fine-print-included final breakdown of the price. If they don’t make you feel comfortable that they are reporting a firm quote, then you take your business elsewhere.

      TWO, while it’s easier to quote what a tummy tuck will cost, it’s not easy to predict what a hospitalization for a kidney infection will cost due to not knowing how the disease progression will vary.

      THREE, as a physician in a surgical field, only part of the pricing is under my control. I can charge my set fee for a laparoscopy, but the total cost to the patient is affected by which OR I use, the anesthesiologist’s fees and the cost of drugs associated with the treatment.

  • http://www.fancyscrubs.com Fancy Scrubs.com

    People don’t think it through enough when they say doctors are paid too much:

    1) The years of college and money it took to go to college to become a doctor – the years it takes to pay the college loans
    2) It’s a 24/7 job with extremely high stress – imagine every decision that is wrong could cause death? Not everyone has that type of stress on their job
    3) Insurance – Sky high cost of malpractice insurance
    4) Other professional licenses and costs that are a yearly fee
    5) Continuous education to keep up with the changing science and new medications – its a never ending job!

  • http://doctorstevenpark.com Steven Park, MD

    Psychology has a lot to do with it. Since someone else is footing the bill, the average person believes that everything’s “covered.” It’s a totally different mentality with the way healthcare is set up, with sometimes multiple 3rd party payors. People don’t flinch paying $1000 for a plumber, since you’re paying him directly. If this country had a plumbing problem epidemic and somehow adopted plumbing care insurance, you’ll have the same kind of issues. Actually, if you calculate the dollars per hour you make as a plumber vs. most doctors, plumbers come out on top (by far).

    Ultimately, we doctors have only ourselves to blame. We bought into the false promises of HMOs a few decades ago and now are trapped in a never ending cycle. Medicine has been fully commodidized. We should stop feeling entitled and practice medicine with the same passion that we started out with when entering medical school, or find another profession.

    • Matt

      “Actually, if you calculate the dollars per hour you make as a plumber vs. most doctors, plumbers come out on top (by far).”

      What numbers is this claim based on? The average physician nets at least 3x what the average plumber makes.

      • http://doctorstevenpark.com Steven Park. MD

        Matt,

        I’m sure if you take into consideration total number of hours worked, expenses, etc., a doctor will net more than plumbers, but there are certain situations where hour per hour, a plumber can make more than doctors. My plumber charged me $1000 to install two sinks for one hour’s work. If you take into consideration time between jobs like this, the average will go down significantly. It’s like a surgeon that performs 5 tonsillectomies in one day, but goes to 5 different hospitals for each procedure (like a plumber would). If you get $250 to $400 per tonsil procedure which takes about one hour each…. you get the idea. Since a doctor or surgeon sees patients back to back, it’s more time efficient.

        • Matt

          That I can understand. There are certain situations where you’ve underpriced yourselves in one area or another. But still, I think you’re kidding yourself if you believe that’s more than once in a blue moon. If it was at all regular, the income disparity wouldn’t be so marked. Your plumber also has to drive to the next job too – unless you have a lot more sinks than the average physician.

          $1000 to install two sinks in an hour? Materials not included? You need a new plumber.

      • Melissa

        How many 36 hour days due to nights on call does a plumber average per month?

    • killroy71

      I flinch at paying $1000 to a plumber.

      But you are absolutely right that when we are using “other people’s money” for health care, we want all we can get.

      This is where health insurers accidentally did everybody a disservice, by pooling the money. But no matter what kind of system we end up with, we have to get it into our heads that it is ALL “our” money – whether premium or taxes.

      • horseshrink

        Decouples normal market dynamics from the physician/patient interaction.

        In exchange, we enjoy shared risk, for so long as resulting supra-inflationary medical costs will allow.

        • http://fertilityfile.com IVF-MD

          Decoupling normal free-market dynamics from the doctor-patient interaction has a lot of bad consequences, both financial and medical.

          It’s possible to pool shared risk without loss of freedom. People can voluntarily choose to support the entrepreneur who come up with the most attractive way to pool risk. No taxes. No mandates. Just healthy market competition for our healthcare dollars.

  • Christina

    I think people that complain about a physician’s “resonable” living are unable to see the value of what you do. All we see as a patient is the three minutes you spend we us and then we are billed $X amount of dollars for those three minutes. I had the VERY BEST Family Practice Doctor. She made it a point to spend time with each and every patient she saw. When I say time I mean at least 45 minutes on your first visit. Follow up visits were often 30 minutes. When I walked in her office, her staff knew me, they greeting me by name, asked about my family etc. When I paid her my X amount of dollars I felt that I wasn’t paying her enough. It was embarrassing to me how little she was paid by my insurance company. She recently lost her job because she refused to see 25 patients a day. The thing is, I would have paid significantly more out of my pocket just to be able to keep her as my doctor. I would never complain how much she made. In fact, she should have been making about 3 times more in my opinion. She developed a relationship with her patients that physicians really cannot afford to do, and for that, she lost her job. So when people complain about the money you make, it’s because for the most part you cannot take the time to develop a relationship with your patients that will show the value of what you do.

    • Vox Rusticus

      Hopefully she will go and open a cash-pay concierge practice where her appreciative patients can actually pay her what she is worth, and she won’t have to see 25 patients a day.

      • JPB

        So she would have to see 3.125 patients per hour. Do you think this is onerous?

        • Vox Rusticus

          If your patients expect 45 minutes with you, it isn’t just onerous, it is impossible.

        • horseshrink

          Or, should it be 3.141592653589793 per hour?

          Pi is a more interesting number than 3.125.

          Numbers nowadays are more important than the widget “patients” they neatly quantify.

          Beats the heck out of dealing with real human misery.

      • http://Www.twitter.com/alicearobertson Alice

        I noticed the author works in concierge service. Vox alludes that they are paid better. Are they paid more, or more easily? Are they really an overall success story? I ask on two levels…one it would seem those seeking this service would be more affluent and maybe healthier? And how much of a market is there really for this? Some doctors really want to help others and their patients see this…..appreciate it…..and do not care what you make.

        I think just as doctors complain about lawyers, plumbers, CEO’s, insurers and you may be part of the problem. What does it matter what others make? Public perception will change as you do….I know a few doctors who are worth their weight in gold…but their skill goes beyond what they learned in medical school…..their combination of attributes, medical skills….and understanding that sometimes an anxious patient’s heart overrules their mind….they perceive that…and give the patient something priceless….and those patients do not care what a doctor makes.

        I tend to think sometimes you simply protesteth too much.

        • horseshrink

          Thought about going back into private practice … cash only this time.

          Income would be better. Administration much simplified. Overhead reduced.

          But … those who could afford to pay me would not be the ones in greatest need of my services.

          I’m very fortunate now to work someplace with regular hours, competitive pay, good benefits … as a state employee. And I definitely take care of the very sickest of the sick.

    • Norm

      The same thing happened to a physician I know. He wasn’t seeing enough patients so when his contract came up for renewal it wasn’t.

  • horseshrink

    I’m not entitled to any certain level of pay. However, to the extent that market forces still exist in our profession, they reach an equilibrium. Wages too low for the work required = undersupply of docs (eventually.) Undersupply of docs drives up wages.

    Confounding variables in the market process … third party payers and government employment. Even so … regardless of who pays the wages, or by what arcane set of formulae … folks will leave the profession early or fail to enter the profession in the first place if the work/pay ratio is unfavorable. Physician supply problems would then create a balancing upward pressure on pay, though the process would be painfully slow. The only way around this inevitable market dynamic would be conscription.

  • http://fertilityfile.com IVF-MD

    There is a significant difference between whether a consumer complains about pricing vs whether or not he continues to choose to pay it. Everybody is complaining about gas prices nowadays. Some people actually take action and carpool, take public transportation, trade in to a smaller car or cut out the portion of their driving that they can in order to BUY LESS of the expensive gas that they complain about. Others who complain maintain their previous gas purchasing habits, unchanged.

    it’s really hard to get people to stop complaining. That is their free-speech right. if they stop purchasing, then THAT would have a greater practical effect.

    This concept is not limited to just voluntary private sector transactions. Former Secretary of State, Alexander Haig, is often quoted (or misquoted?) as having said regarding political protesters, “Let them march all they want, so long as they continue to pay their taxes.”

  • PAULMD

    Vox, I couldn’t have said it any better. The points are well stated. Thanks.

  • JPB

    There are several very different perspectives here.
    1. We have the doctors complaining all the time about not being paid enough. Then we have the Forbes report saying that in 2009, primary care doctors were earning a median income of $190K plus. So what should we believe?
    2. Then we have the very inflated compensation packages of executives in large medical care organizations. Doesn’t this have to change?
    3. We also have primary care docs insisting that their patients submit to all kinds of tests, some of which are probably the result of “defensive” medicine rather than honest necessity. How is the average person supposed to deal with this barrage?
    4. Finally, there is the unfortuate fact that many primary care doctors will “fire” a patient who doesn’t agree with, or follow all the dictates for, drugs or tests that are prescribed because of one-size-fits-all “protocols.” Is this truly honest and ethical practice? I don’t think so…….

    • http://www.BocaConciergeDoc.com Steven Reznick MD

      Medical Group Management Association median salary figures are probably more believable than Forbes. Some studies include obstetrics and gynecology in primary care and they earn multiples of what the median family practitioner and general internist actually earn. Its all about how you define primary care. In addition many physicians are now accepting hospital based positions as hospitalists and are being paid significantly higher than their outpatient colleagues who treat patients longitudinally not just episodically

      • doctor1991

        Remember that when OBG salaries are described, it’s usually from one of the recruiting firms that include the cost of malpractice insurance and other “benefits” in the pay, often increasing it to $100,000 more than the actual take home pay before taxes.

    • pj

      a few issues here… Median is often misleading compared to mean.

      Please define “medical care organizations” Do u mean insurance co’s, large group medical practices, or what/

      There is nothing dishonest about a Doc telling a pt they need to seek care elsewhere. I also don’t think it unethical, generally speaking, as good care depends on trust between a pt and Doc. If there is no trust, it may be seen as unethical for the Doc to continue the relationship.

    • Family Doctor

      The doctors in my large city are making 130 K to 170 K. And working like dogs to get it.

      I would love to make 190 K. Would love to.

  • Steve

    I think there is a perception in society (not my personal opinion), generally speaking, that all doctors are (or at least, should be) practicing medicine for altruistic purposes. How could someone whose position in society is to help treat and cure the sick have any other reason for going into such a profession, people think. Most doctors undoubtedly have a genuine desire to help people, however, why deprive them of wanting to enter the profession for love of the science behind medicine, lifestyle flexibility (for certain specialties), community prestige, money, or any other reason? Can you imagine someone who can’t afford a product/service entering a store/office and taking/utilizing that product/service because they don’t have the means… without recourse? Imagine that scenario happening in any other profession other than medicine… yes, it comes with the territory, and forget the fact that the poor and indigent are being subsidized. Most doctors won’t think twice (even if they are legally bound to) about treating someone critically ill or injured without the means to pay for the treatment.

    Notwithstanding all that needs to be fixed in our broken healthcare system, I am one that believes doctors are underpaid for what they do. For the years of sacrifice in schooling and training to the magnitude of impact they can have on people’s lives, doctors should be well-compensated for what they do.

  • John Ryan

    “there is the unfortuate fact that many primary care doctors will “fire” a patient who doesn’t agree with, or follow all the dictates for, drugs or tests that are prescribed”

    This is because in many states (including mine), the legal system holds the physician responsible for the patient’s bad outcome, despite a failure to follow recommendations. This paternalistic responsibility means that it is “safer” for the doctor to dismiss a noncompliant patient, rather than to try to treat someone who ignores his recommendations.

    If if you think this sounds bad now, just wait until “pay for performance” programs determine a doctor’s pay. Noncompliant patients and those with difficult to treat conditions will be let go in a heartbeat. Just another unintended consequence of our beneficent government reforming medical care.

    • horseshrink

      Hadn’t yet thought re: how human docs will jostle against one another to cherry pick in a “pay for performance” world.

      Yup. I believe you’re correct.

      So, the all-knowing bureaucrats will then try to patch that hole in our Skinner Box with more duct tape mandates – with their own unanticipated sets of consequences.

    • doctor1991

      Exactly right.

  • Med student

    The reason why people have trouble with physicians earning a handsome income, I believe is several fold. First, people can live without a wal-mart executive, or a lawyer, or what ever other high earning profession you like, but patients cannot live without a doctor. Secondly, physicians are viewed as more heroic, more noble, more honorable, etc. They are held in high esteem, and people enjoy the sense of knowing they are being treated fairly and honestly. People expect lawyers to screw others over to earn more, but not doctors.

    That being said, I will not work for <200K/year. I have debt to pay.

    • Melissa

      You should probably, unfortunately, avoid primary care then.

  • Joe

    I think we all make a mistake by lumping all physicians together when we look at whether they are paid too much. Probably some are paid too little, perhaps PCPs, and some specialists make way more than reasonable. I also think we folks are often thinking of the doctors who are really administrators at big healthcare systems. We often feel these docs make too much.

    When one is pulling in lets say 25 to 50 times the average income, we righly start to ask why? At 50+ times the average salary we say that’s too much and we suspect that its the position they occupy, not their skill or dedication, that allows them to make that much. We question their ethics.

  • soloFP

    Reasonable living varies. Most people can live in $50,000 a year and feel that $100,000 is a good salary. Most docs make between $120,000 part time to over $600,000 a year for subspecialists. That said, most docs work 50-60 hour weeks, which means a typical 40 hour job comparison would be to multiply a random job comparison by 1.5 to equal a doctor’s job.
    As a solo doc and if I take a day off, no income comes in. My retirement is what I save. I have a malpractice insurance premium in Primary care in a high risk county/state that is $33,000, despite never being sued. My average insurance visit payment is $60, including the $30 copayment. The only way I can increase my salary is to see more patients and work more hours, which is what I have done in the last 6 years. I have maxed my salary to above the national average and enjoy a decent lifestyle by seeing more patients each day. Non docs would tell me I make too much instead of telling me that I am successful for the extra hard work of starting my office two hours earlier than the average doc in my area and often working through lunch.
    On the flip side, I feel lucky, as I have paid off my building and med school debt early. I have patients who make less than I make in 1 day when they work 1-2 weeks. I do make a reasonable salary, but it takes 60 hours a week to do so.

  • http://Www.twitter.com/alicearobertson Alice

    To the average patient who knows doctors earn five times what they are earning this just comes across as sour grapes. This article, also, makes me appreciate my own doctor who shares the real reason he became a doctor was to help others. He never complains about anything except his colleagues. You do not feel like a victim of the meat mentality with him….you feel like an individual he cares deeply about…that his greatest compensation is in helping others…realizing he is paid much better than the person he is treating.

    There is nothing in this article to make us think you are worthy of more money, or pity, or respect than the average Joe. I think doctors are paid fairly considering your sacrifice. But almost every person I know is drowning in student debt, job stress (more than doctors who rarely get laid-off), long work hours. Teachers have one tough job and if you compare their ratio of student debt to earning capability your complaint is evaporated. The good teacher has a 24/7 job and I hope someday their union will consider bonuses for the great ones.

    I am not worried about doctors quitting…maybe someone who sees the job as an avenue to serve society will replace you. Where I get care…ay Cleveland Clinic…there are doctors wanting in, not out. They take less money, deal with heavy duty management that places patient’s in the driver’s seat (well…in theory), and they concentrate on patient’s moreso than coding, etc. It is a trade-off….and it is working. Yes, there are problems…but the whining beast there is tamed.

    • horseshrink

      “It’s time we in the industrialized nations admitted what safe, comfortable and fun-filled lives we lead. If we keep sniveling and whining, we may cause irreparable harm to the poor people of the world – they may laugh themselves to death listening to us.”

      P.J. O’Rourke
      Parliament of Whores

    • Melissa

      Wow.
      Your opinion might be frustrating but it is so oblivious to the realities that it only frightens me. If this opinion is common, it really will take conscription to supply this nation with doctors 20 years from now. It is amazingly conclusive for someone who likely does not work in the field and thus has a VERY large blindspot to how the system works. This type of quick conclusive opinion may be a symptom of the Dunning-Kuger effect.

      I do agree, however, that GOOD teachers are way underpaid. Although, I do not work in the system and may have many blind spots. I would have to have a lot more exposure than just having a child in one teachers class to form a more conclusive opinion.

      • pj

        Well… I doubt conscription will be needed since the defacto solution for the PCP “shortage” is dilution with midlevels (NP’s and PA’s) as many of us have seen.

        Please see Alice’s comment below. That one better reflects her outlook. She has been thru huge convulsions with family health issues and still has perspective, humor and wisdom.

  • gzuckier

    Well, I put 8 years of slavery in after college, in grad school, cooking up some of those pharmaceuticals patients are grateful to their physicians for (well, placing my tiny brick in the wall, more accurately) so I can sympathize with giving up most of what is arguably the best decade of your life. And after getting my Ph(oney)Doctorate and spending years postdocing I can also sympathize with the post-graduation grind and time commitment. The difference comes in the fact that after several years, I could no longer force myself to live on the pittance postdocs get while looking for a spot to open up on the bottom of the academic ladder somewhere, and bailed out of the whole biz into something less benevolent but more lucrative. So, i guess at this point my sympathies fail to keep up with those who are feeling financially challenged and unrewarded for their years of work, despite making probably doube what I was making at the same point after the same amount of work, in a general arena where neither of us could work effectively without the efforts of the other. It reminds me a bit (but not as extreme) of an op-ed I just read today explaining how the Obama administration’s tax cut threshold of $250,000 for a working couple hardly constitutes wealth, despite this being the 97th percentile (actual figures from the article) of income in the US.

  • horseshrink

    Those who want to become “millionaires” are not well advised to choose the profession of medicine. It is not the fastest or easiest way to get there.

    • http://fertilityfile.com IVF-MD

      I agree. Be that as it may, there are other factors to consider. Who would rather make 100K per year helping solve people’s health problems and who would rather make 200K+ per year suing kids who download music or suing mom and pop businesses that don’t have regulation handicapped access ramps? :)

      • http://Www.twitter.com/alicearobertson Alice

        Very few of will have that opportunity. But I am grateful the opportunity to make money is still there for doctors and lawyers. Even in their bad behavior or earnings beyond their real worth (which is rare) they are invaluable when you need them. The problem is both occupations have a subset preoccupied with money…..and the whining is like screeching in the ears of those who pay you, but are made to feel like charity cases. You want our gratitude….and maybe laying a little lovin’ on those who help you make that living could change the perception of your detractors?

        IVF…..you are worth every penny! :). I get the feeling your patients are feel in’ the love.

  • Lisa

    “Why does society frown on doctors earning a reasonable living?”

    I believe there is some matter of perspective on what constitutes “reasonable.” I think most people judge reasonable based on what they make. Let’s say I make $25,000 doing my job –$100,00 may seem perfectly reasonable for a physician–I know they are more educated than me, have more responsibility/risk. But do they work harder than me, are they better people, deserve it more?

    It’s hard for most people to come up with a “reasonable” amount of income for someone else–unless of course they are a professional athlete. Million(s) dollar contracts seems the norm and not many complain…

    • William D. Strinden MD

      Type your comment here.   Last night I was called to the ER at 10:30 to see a motorcycle accident victim due to an extraordinary foot wound. (I am a Plastic& Rec,Hand Surgeon).    Due to other multiple fractures she was shipped to a trauma center, but I was out on Sunday night until midnight.   The night before I started surgery at 10:30 pm and was sitting in recovery at 2:30 Sunday morning chatting with the patient who had a gunshot wound to his hand… accidental, unlike so many others over the years.  About half of all my ER calls are entirely indigent or non-paying.  Young men with trauma do not pay their bills.   The patient  in recovery asked me what time my shift was over.  He was flabbergasted to know that my “shift” on the weekend is 48 hours and that I am on call every third day and night of my life and that I routinely work 70 hours per week 6 to 7 days per week.  He works for an oil company in a refinery.  He works four 10-hour days on one week, three days the next, then he has an 8 day hiatus.   His take-home pay is 2/3rds of mine.   In comparing my net worth at age 56 with two high school friends who started farming right out of high school, I am dismayed  to know that each of them has  over twice my net worth.  When people ask me when I will retire I must sadly confess that I will likely work until 70.   Surgery is rewarding but the time committment for education and the time required to earn a living, not to mention the ever-increasing burden by every tin-horn bureaucrat  make it economically foolish for a smart and able  young person to choose medicine.   I celebrate the fact that none of my four national merit scholar children chose medicine as a career.   As Uwe Rheinhardt stated, “Most doctors could do the jobs of those people on Wall Street.  The reverse is not the case.”   I am a talented guy, capable of doing many, many more things which would earn me more money than a career in medicine has.   My money has been earned doing piecework, no differnt than a dry-wall hanger.  Much of it is entirely free-market, people eager to pay me for a service they want.  If too many  people are hostile, thinking that I earn too much, they might just find themselves without me when they turn up in the ER at midnight. 

    • Anonymous

      Reasonable means I can pay back my loans. 25000 may be reasonable for someone who spent money only on an undergraduate degree, or who has no advanced degree at all, but please keep in mind that your doctor starts residency ~300k in debt these days. Residency salaries are paltry at best, and loan repayment begins during residency. New attendings may make 6 figures, but they still have quite a long way to go before they emerge from the hole their debt has dug.
      Further, I am not aware of many full-time jobs that require their employees to work 80h weeks and take 30h calls. Obviously people who are not doctors work just as hard, and care just as much…but the burden is in no way the same.
      So I would say that at least 10000 is reasonable, and honestly perhaps even not enough just considering the financial balance.

  • http://www.fancyscrubs.com FancyScrubs.com

    Why do people feel athletes make reasonable incomes in the millions but doctors over $100,000 is not reasonable?

    • stitch

      or how about bankers who make multiple millions of dollars taking risks with other people’s money, and who make that kind of money whether they make or lose money for people?

      I have less problems with the athletes, frankly; someone else is making a heck of a lot more money than they are, they do get paid according to performance, and their careers are short.

      The careers for docs are relatively short, too; we start our careers later, and for many procedure related specialties in particular, it’s hard to continuing practicing after a certain age. And while I’m not on the tort-reform bandwagon, it’s important to realize that one bad tort outcome can be the end of a career.

      But back to the bankers. I think we med folk need to realize that part of the frustration for at least some of us is that we have watched those who washed out of pre-med go on and become lawyers, go into banking, or frankly go into medical sales – and they are making far more money, they get to have lives, and no one gives a squeak about that.

    • Jack

      because there is no $20 co pay. LOL.

  • killroy71

    I don’t feel athletes and other performing artists make “reasonable” incomes — but I defend them getting it because (1) they are making OTHER people even MORE money; and (2) the money they get is paid voluntarily – by suckers, but there you go

  • http://fertilityfile.com IVF-MD

    Athletes and musicians make their money on purely voluntary terms. Nobody forces anybody to watch sports nor listen to music. Even better, nobody forces anybody to support THAT particular athlete nor THAT particular musician.

    If one dissects the way that bankers and professional stock traders make money, it gets really interesting. What forces are in play that drive the common man (clueless about the game of investments) to put his chips at risk playing with the professional sharks? It’s because he knows if he doesn’t make his money grow and instead just hides it under his mattress, that it will lose purchasing power year after year (also known as inflation or dollar devaluation). This is an artificial situation created by the Fed. OK, off topic, I know. But the point goes back to this. Healers provide a real product that people are eager to pay for voluntarily. Entertainers do also. On the other hand, in most cases, government workers and corporate entities that rely on government favors gain their money by force. Once one realizes that, things will start to make a lot more sense.

    • horseshrink

      I don’t begrudge athletes their incomes. (Neither do I pity them when they complain.) The market allows those incomes. I’m not required to go to football games (unless, maybe, I live in Green Bay). No problem.

      Government … another story. (And I’m a government worker!)

      As PJ O’Rourke so elegantly points out, government has the power to enforce its money grab with guns. Try not paying your taxes and going to prison. Then try to walk out of prison. Guns.

      • Norm

        I live in Green Bay and I still don’t go to a game. I am still angry that I have to pay a 1/2% sales tax to renovate the stadium so players making millions can play football.

  • Norm

    People think doctors make too much money for the same reason they think drugs cost too much money. Politicians have been telling people “health care is a right,” when something is deemed a right, people think they should get it for free.
    People don’t mind paying $10.00/day for medication to grow hair, get an erection or lose weight but they don’t want to pay $1.00/day to control their b.p. or lower their cholesterol.

    • http://fertilityfile.com IVF-MD

      I agree. I would add that if someone doesn’t want to pay $1/day to lower their BP or cholesterol, they shouldn’t have to pay. Somebody else shouldn’t have to pay neither. It’s their free choice not to take the pill. Besides, who says that taking a pill is better than controlling ones body weight in a healthy fashion?

    • http://www.medi101.com Medical apps

      I think you are apsoloutly right Norm.

  • Jackie

    I’ve been my family doctors’ nightmare for over 20 years. None (yes, ‘none’) of my family doctors has ‘ever’ diagnosed the serious medical conditions I had. Several of them had threatened me either with a referral to a psychiatrist or avoided me after I had become a ‘liability’.

    Can’t blame them. I look trim and fit. ‘Most’ of my tests look normal. They couldn’t not see through my skull to find the brain tumor. Even the specialists were fooled by the young doctors who had misread my mammograms. So the recurrence of my breast cancer was not found for almost four years.

    I’m still alive because I had trusted my instinct (though almost too late each time) and my training in medical librarianship, I’m still alive because I live in a ‘medical town’ where even an unassuming library volunteer could turn out to be a retired pathologist who give me a ‘push’ to persist in my quest to solving the life-long mystery.

    Nobody would ‘frown on’ the doctors who are truly life-savors.

  • Bob

    Due to increases in regulations, various legal issues, and the fact so much time is spent on actions not visible to the patient i.e. charting, EMR, orders, coordinating with other medical team members, and reviewing test results, there’s an extreme disconnect.

    They are given short windows to interact with their physicians. Treatments are handed over by either staff nurses or pharmacists, as required at most hospitals. Essentially, all the patient sees a physician doing is asking questions and doing a physical exam. Sometimes even those are lacking with many (maybe even most) physicians covering more than 30 patients daily.

    I think patient opinions have changed because the roles that physicians take in their care has largely changed. We simply aren’t allowed to work at the front line anymore.

    • http://Www.twitter.com/alicearobertson Alice

      I agree…but this has become a bit of a double edged sword for doctors. To serve your patients dealing with insurers, and government become part of the job. Sure a certain segment can attain concierge service level…but that just isn’t going to serve the masses. And where I get care they complain incessantly about the arrogance of the rich. Not every doctor wants to serve that type of patient.

      That said big changes are coming. The IPAB (Independent Payment Advisory Board) may rule doctors in a fashion worse than today, and Medicaid reimbursement could become so low it isn’t worth it. But one wonders if the day will arrive when doctors have no choice in the matter? You could eventually be regulated into compulsory service to mankind by government appointed boards?

      • http://fertilityfile.com IVF-MD

        Alice, if that day comes, when our only choice as doctors is to be managed by the state and be the equivalent of a government worker bee, clocking in and clocking out, following protocols written by non-practitioneres, I forsee a lot of the better doctors leaving to do something else. It’s bad enough already today with how much compliance work we are forced to do, taking away time that we can spend with our patients. It’s not just regulations that push us to do non-clinical activities. It’s also self-preservation from lawsuit abuse. Still, I’m grateful that a % of my daily activities still involves rewarding patient care and human interaction, enough to make my job fun and fulfilling. That day may change. I hope not.

        • http://www.newser.com/user/83561792/1/roland47.html GodlessLiberal

          Just curious if you think that doctors in Canada, France, Germany, UK, Spain, Switzerland, Denmark, etc. aren’t making a reasonable living? 

  • http://bioscientificediting.wordpress.com/ Nicky

    I agree completely – much of society definitely sees doctors as people who should be completely altruistic – giving up their time and expertise for free (and immediately when they are called upon – preferably “yesterday”!). I am a veterinarian (although I no longer work in private practice, but in medical research now) & see this as a problem in our profession too. Yet somehow, many of the same people think nothing of purchasing a non-essential designer handbag, item of clothing, or a ticket for a sports game for a few hundred dollars.