Does longer physician training merit more pay?

One of the main considerations in physician pay under CMS’ relative value system is the training required to complete a task. This is generally thought to be well understood but is, in fact. a quagmire of controversy.

Take for example the specialty of family medicine compared with dermatology, anesthesiology, or ophthalmology. Family physicians make between 1/2 and 1/3 of what these other specialties make, so one would think that there is a huge training difference. The truth is that each of the four require 16 years before medical school, 4 years of medical school, and 3 years of residency.  The 3 highly paid fields require 1 additional year in a transitional internship.  So the family physician education represents 23/24 or 96% of the length of education required for the others.  Since when is a 4% investment worth a 200% to 300% return?

There are, of course, longer training programs.  Internal medicine fellowships are 2 to 3 years on top of a 3-year residency.  There was a time when this made sense, since the idea was to educate competent general clinicians and then for them to specialize in a narrower field.  Given the limited general physician work of, let’s say, cardiology, one could easily argue that the 3 years of internal medicine training are wasted. Should cardiologists, therefore, be credited with 23 or 26 years of training? It would obviously be more efficient to move these physicians directly from medical school into the cath lab.

There are some physicians who keep going on and on in their training, completing one residency and then another. One fellowship and then another.  CMS must come up with a numerical way to appropriately compensate these individuals for their time, yet discount it for any lack of relevance that their training might have for performing a particular procedure.  Take, for example, the resident who completes his general surgery training then goes on to do a fellowship in vascular surgery, then goes into practice and limits his practice to the laser closure of veins, a technique he learned in a weekend CME meeting.  Should this physician’s income reflect 7 years of training or 3 days?

I have always argued that the year you learn the most is the year you first go into practice.  It would certainly seem appropriate, then, to give everyone credit for this 1 year of training.  But what do you do with compensation for training after that, given that almost all physicians are engaged in work that requires lifelong learning?  It would seem a reasonable solution to give credit at .5 of a YOT (year of training) for that first year and for up to 20 consecutive years. After that, you would subtract .25 YOT for each subsequent year, acknowledging that some of what you had learned by that time would be out of date. Passing a mini–mental status exam on an annual basis after age 60 would also be required to know whether any financial advantage at all should be given for previous training.

It would obviously be essential to add training income for CME.  I would personally be opposed to awarding such training time for drinking coffee in the doctor’s lounge while watching FOX News.

So, be very careful when you emphatically state that all of your long education merits more pay.  Someone may want to actually count.

Paul Fischer is a family physician who practices at the Center for Primary Care.  Along with 5 of his colleagues, he filed suit against HHS and CMS to challenge the illicit relationship between CMS and the RBRVS Update Committee (RUC), which has shaped the current payment system. This article originally appeared in Care and Cost.

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  • http://www.facebook.com/paul.c.weiss Paul Weiss

    Pay should be based on the relative value of the procedure to the patient, reflecting responsible utilization of our health care resources. What’s worth more…a cardiologist inserting a stent into the coronary artery of a stable patient with a blockage? Or a GP spending 40 minutes with the patient setting reasonable goals for improving their health with proper diet and exercise, with appropriate follow up to monitor their progress?

    One thing that is grossly undervalued is time spent with a patient.

  • Anonymous

    Tell that to geriatricians whose longer training actually earns them lower pay, due to the fact that almost all of their patients are on Medicare!  It is no wonder why few physicians are interested in geriatric fellowship training.

  • Anonymous

    Physicians are compensated differently based on their specialty.  It might be worth sacrificing pay to do something more in line with what you love.  For example,

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    are more difficult than dermatology, but a physician might find neurosurgery more rewarding.<!–
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  • http://www.facebook.com/people/Craig-Koniver/100001463176810 Craig Koniver

    Thanks for sharing your interesting perspective! I feel that the coding and reimbursement system is terrible and way off-base. We reward procedures and undervalue the interactions between PCPs and patients. Yes, triple by-pass surgery is technically more difficult than talking with a patient about diet and exercise. The current system places more value on the surgery while I believe more value comes from the interaction with patient and creating a wellness plan. It is no wonder that our society behaves as we are leading them–much easier to just take Lipitor and not eat well or exercise compared to actually being in charge of your own health. At the end of the day, the patient knows that they can just get the by-pass surgery. True health is a big committment requiring patients to spend time, energy and money on eating well, exercising consistently, thinking good thoughts and taking high quality supplements. We encourage the relying on the pill only attitude by the way we have shaped our very own health care infastructure!

    • Anonymous

      It’s interesting the primary care has latched on this idea that their mission in medicine is to give diet and exercise advice.  Really?  You racked up hundreds of thousands of dollars in debt just to do what a dietitian and a personal trainer does?

      I have a friend who is overweight and is working with a personal trainer.  He helps her with her diet choices and created an exercise program that met her special needs.  He motivates her with frequent communication.  All this for $50 an hour.

      I value surgery.  I wish my PCP would have excise that tick bite instead of sending me to the dermatologist.

  • Anonymous

    Yes, those with more training should be paid more- this is a no brainer. If the patient does not require a specialist , then they can be managed by a generalist. This is not at all meant to devalue the work of  generalists.

  • Anonymous

    This is a rather misleading commentary. Most surgeons and proceduralists do not do multiple residencies, nor do they learn their bread and butter procedures at a 3-day course. Instead, most are spending 5-7 years of their life in residency, incrementally developing hard-to-acquire technical skills that only come with time and experience. Dermatology aside, many specialists are spending 4 years of residency and an additional 2-3 years of fellowship (7 years of overall training vs. 3 for the family doc, not quite the 1 year differential.)Sure, some stents take 10 minutes, and some scopes take 15 minutes – but when something out of the ordinary happens, wouldn’t you want your physician to have the most experience possible? Its not “length” of training that merits pay, but its the intensity of the training, acquisition of experience, and the rarity of the developed skill that presents value, not to mention the concentrated risk. The “per hour” effort simply is not worth the same amount. 
    Why not flip the argument? Nurses also go to grade school for 12 years, followed by 4 years of college, and another 2 years of nursing school (18 years total), which is 75% of the 24 years it takes to train a family practitioner. Since when is a 75% investment worth 200-300% return? What justifies a family practitioner making 3x more than a nurse, or 2x more than a school teacher, by that logic?  Why should the family practitioner, who chose an additional 7 years of post-college training, make more than those who only finished college? And then, why should one negate the value of those who chose to study for 10+ years after college to achieve specific procedural skills (4 years of medical school, another 3-7 years of residency, 1-3 years of fellowship)?Sorry, but not all training is equal – and not all specialties are equal. Some are longer (and in many cases, much longer), but there is also variables of intensity, rarity, physicality, and risk that this author’s analysis neglects. If you start paying the cardiac surgeon as much as a family doctor, there will not be any cardiac surgeons to take the patients you refer for CABG.  Reduce the amount of training required to be a neurosurgeon to 3 years, and you won’t have many neurosurgeons who can safely take out a brain tumor. Not all of us are doing cases we learned at a three-day course, or learning by reading “Surgery for Dummies”. I understand your frustration with the overall decline of reimbursements, but please, don’t put down or minimize those of us who have worked very hard (like you)  for the special skills we have EARNED. 

  • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

    Whatever value is placed on specific services should be the opinion of the patient, not of a third party. So what if I hypothetically believe that my speaking for 90 minutes with a patient exploring strategies for weight loss might help her get a baby more than just my doing a 15-minute insemination. If she is unwilling to pay more for the nutritional counseling than for the insemination, then she has spoken. It would be wrong for me or a third-party to say to her “WE believe that B is more valuable than A, so we mandate that you pay double for B what you would pay for A”.

  • http://www.facebook.com/rfdbbb Robert Bowman

    Training in an area of primary care is mostly about the years of primary care experience after training. The concept of training length is quite ridiculous compared to years of experience, volume, complexity, and the patient after patient application of “buck stops here” focus on patient needs.

    Any hope for the US to survive economically must involve lowering health spending – spending that cripples local, state, and federal governments and nearly all businesses as they have fewer to do the work due to more and more paid in health care costs requiring budget shifting with fewer personnel and more paid for health care . Inefficient and ineffective is not a good choice for America in a very competitive world market.

    Any hope for primary care (stagnant by design with revenue insufficient to cover the costs of delivering primary care) must involve increases in revenue, decreases in costs, and increased workforce efficiency. Current designs force higher costs, result in more new areas of spending (technology, HIT, regulation) decrease revenue generation, and hamstring key personnel such as primary care nurses (that end up working for insurance companies to save them costs).

    Reductions in non-primary care spending are required to balance budgets, decrease costs, and address the gap between non-primary care and primary care.

    The US needs a balanced workforce and imbalances due to archaic funding mechanisms shaped by those who benefit most from the most lines of revenue and the highest levels of spending in each line – will not do anything other than to shape more and more workforce toward practices in existing top concentration zip codes where 50% of the workforce is found in 1% of the land area and 75% is found in 4% – leaving 65% of the population outside by design.

  • Kevin Samolis

    Compensation based on amount of training?  Most of us outside of medicine and government are compensated based on merit.

  • http://westcoastglaucoma.com Rob Schertzer, MD, MEd, FRCSC

    When I went through my Ophthalmology and Glaucoma subspecialty training, I was fully licensed as a Family Doctor following just one year of medical school because back in 1989 that was all that was needed. Please also note, Ophthalmology is 4 years after a mixed year, not 3 years, and subspecialty training is 1-3 years after Ophthalmology. So, I actually did 6 extra years to be a glaucoma subspecialized ophthalmologist. So that would make family medicine vs glaucoma specialist graduating more than 10 years ago would have spent 23/29 years in school….ie more than 25% more time in school. Probably therefore worth some extra pay for time in school….so that counts for about a 25% premium. 

    Now, what of office overhead? I currently have staff, equipment payments, rent that require over $600K per year just to cover the costs of running the office. How much is the overhead for a family physician these days? I think this more than accounts for the need for 2-3x the remuneration just to cover the costs. Time in school is just a small part of the equation.