How do we know what a doctor is worth?

I read the recent popular posts from Matthew Moeller (Dear lawmakers: this is what it’s like to be a doctor today) and Nick Rademacher (Lawmakers shouldn’t care about the personal hardships of doctors) with great interest. They reflect perspectives from two interesting turning points for most medical careers- medical student, and established attending physician. I’m a U.K.-based surgeon and though the healthcare systems in the UK and USA are very different, the issues of student legacy debt and pressure on remuneration for doctors are similar. Ruminating on both letters led me to consider what a doctor is worth.

Many doctors in the US and UK will empathize with Moeller’s situation, and feel a degree of unfairness in the way we, as a profession, are portrayed in the media by devious politicians. It’d be easy to dismiss Rademacher’s reply as the enthusiasm of youth that will change with age and experience, but I’m wary of castigating him for expressing views that many shared at his stage of training. I‘m sure they are sincerely held, and are indeed the heart of why most of us ended up in medicine in the first place.

Behind these two opposed views lurks a more significant issue: the influence of medical reimbursement on the future direction and structure of healthcare. Like it or not, doctors are the critical decision makers in the majority of medical interactions. Once the decision is made, certain tasks can be delegated to specialist nurses, but the critical decisions are always made and reviewed by a doctor. It’s the decision-making capacity that makes doctors the indispensable part of health care- the part of the system that actually adds real value to the patient outcome.

There are many aspects to the compensation package for a doctor- the job satisfaction, sense of personal vocation, and other intangibles, do go some way to mitigating downward pressure on financial remuneration. But it’s these personal rewards that are cynically exploited by policy makers to force down the financial rewards of the medical profession.

For the majority of doctors, idealism eventually butts up against the hard reality of economics. If the decision makers, the engine room of healthcare, are put in a position where their financial remuneration does not reflect the personal investment in training, nor allow them to enjoy a reasonable standard of living, then the inevitable consequence will be an exodus from certain specialties and activities into other areas which are better compensated.

The end result may be a stratified system of care. The best and most energetic medics could end up treating the wealthier members of society, who can afford to pay for their services, whilst the less affluent patients are left with a dwindling number of overworked idealistic doctors grinding themselves into the ground in an attempt to prop up a public health service under continual and excessive pressure. Healthcare will become more unequal, which, in curious irony, is the polar opposite of what most policy makers say they intend.

So, what is a doctor worth? In the final analysis this probably rests on what the purchaser of a service is prepared to pay for it. In many other walks of life there is a direct correlation between price and quality — isn’t it possible that this rule may also apply to medicine?

Eddie Chaloner is a vascular surgeon who runs a private practice Radiance Health in London, England. He also works part time for the National Health Service.

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  • doc99

    You keep using that word “Reimbursement.” I do not think it means what you think it means.

    • Ian

      Inconceivable!

  • buzzkillersmith

    Worth and price are two very different things, in and outside of medicine. This of course is not understood by some dimwitted enthusiasts. Others refuse to acknowledge it because it is to their benefit to not acknowledge it.

    It is true that price is what the purchaser will pay, but worth in medicine is actually determined by the marginal decrease in sickness or death that a doctor’s contribution makes. I would submit that worth and market price, at least in the US, differ by a wide margin. I make no comment on the UK system.

    Medical students realize this. Hence the PCP shortage.

  • ProudOkie

    “Like it or not, doctors are the critical decision makers in the majority of medical interactions. Once the decision is made, certain tasks can be delegated to specialist nurses, but the critical decisions are always made and reviewed by a doctor.”
    Hello Dr. Charoner,
    Just wanted to point out that in the US, there are at least 17 states where other health care providers, mainly NPs, practice independently of physicians. In many other states such as mine, they are only involved in signing a piece of paper for our prescriptive authority. So NPs are also the “critical decision makers” in many acute and chronic medical interactions. Once they decide, certain tasks may be delegated as well. I am in no way being oppositional or argumentative – just wanted to point out the above statement is not true. The title of “Chief Critical Decision Maker” does not rest only with physicians in our country. Not being able to be the only profession to make these decisions may decrease your overall worth in the eyes of some, but I don’t believe that is true.
    Speaking respectfully…..

  • morebuzzkills

    But in Michael Moore’s documentary ‘Sicko’ he shows that all NHS
    physicians are happy and enjoy a high standard of living…I don’t
    understand.

    [sarcasm intended]

    You’re already seeing the stratification of care in the US, especially in primary care…hence the growth of concierge medicine. The pending influx of patients will likely be accommodated by mid-level providers. It takes 2 years of post-college training to mint a PA or NP…a physician takes 8 (at best). The naive idealist might find himself/herself in charge of a platoon of mid-levels, depending on the practice rights afforded to mid-levels. Where does this leave primary care physicians? I’ll let buzzkillersmith answer that one ;)

    • buzzkillersmith

      Hard to say where it leaves us, but I am not optimistic. The PCMH model says that we will surrounded by large numbers of dedicated professionals–midlevels, nurses, MA, etc., who will all work at the top of their licenses to provide excellent, timely, patient-centered care.

      All that and a bag of chips.

      I guess it might happen. I can’t prove that it won’t. But things could evolve as follows: PCPs will be blasted from morning till night with one complicated patient after another. We will spend hours per day inputting data into soul-crushing EHRs. We will get emails from MAs, nurses, etc, about patients that come their way and, guess what, require a higher level of care, and on an urgent basis. Perhaps we will get around to seeing the emails at around 630 pm.

      Perhaps we will be buttonholed by our midlevels. That routine diabetic check? Well, the sugar is 500 and patient has a fever. Would you mind taking a look?

      And please make sure to answer those 2 page patient emails in a timely fashion. You know, the ones that document a dozen chief complaints and ask if you could call back.

      And please not the electronic communications that documents the fact the several of the patients in your panel, including many you have never seen or even heard of before, are overdue for blood pressure checks, A1cs, earwashes, you name it.

      • morebuzzkills

        Hit the nail on the head. The most effective PCPs will be those ‘idealists’ who figure out how to manage mid-levels and EHR most efficiently. Is that why most people go into medicine? Especially primary care? No…but those are the incentives the policy makers have set forth. Is the holy grail of ‘continuity of care’ and ‘patient centered care’ optimized under this model? Try not to spit coffee out your nose when you think about that one. Never mind the effect this might have on actual physicians working under this system (we aren’t supposed to care about them). On the other end of the spectrum, you will see a growth in concierge care for the wealthy. Depending on the chaos once the influx of 40 million plus starts wringing the system, there could also be a significant growth in direct pay care. Is this the ‘equity’ and ‘social justice’ that our country supposedly strives for? The real impending health care thundercloud is when the baby boomer PCP’s start retiring in droves. An overlooked attribute of this group is their experience and efficiency in caring for patients. Supply will be cut (both by retirement and a lack of students entering PCP fields), demand is increased…you all know the rest of the story. But wait, idealism will survive all this and everything will just work itself out!

        • buzzkillerjsmith

          You are correct, sir. There’s an excellent opinion piece by Jeff Goldsmith at the Health Affairs blog that blows Linda Green’s foolish, silly article in Health Affairs out of the water. You know , the one from a couple months ago that says we can solve the shortage by introducing primary care cyborgs or something.

          • morebuzzkills

            I’m guessing you’re talking about Goldsmith’s article from 3/28. Green’s article had me in tears when I read the abstract. I didn’t even bother to go through our school’s proxy to read the whole article. Any time I see anything that begins with, “We used simulation methods to provide estimates of the number of primary care physicians needed,
            based on a comprehensive analysis considering access, demographics, and changing practice patterns,” I do my best to ignore whatever is coming next. Makes me remember my dark days in business. Saddest thing is that study was probably astronomically expensive and 100% useless. Oh well.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Not useless at all. This is how “policy makers” are informed.

    • trinu

      Perhaps physicians for the NHS can enjoy a decent standard of living for less pay because the cost of attending med school in the UK is so much cheaper than it is in the US. Ergo, no gargantuan debts to pay off.

      • morebuzzkills

        Certainly a component…but this by itself would not prevent students from entering more lucrative specialties. You would probably see a marginal increase in PCP supply, but it wouldn’t be on a scale large enough to address the crisis in primary care. PCP’s must be properly compensated for the care they provide for the current trend to reverse.

        • M.K. Caloundra

          There is not nearly as big a gap in remuneration between GPs (PCPs) & specialists in the UK as there is in the US.

          These are older figures (from a 2004 OECD report), but the overall comparison still holds.
          US GP: $146K
          US Specialist: $236K
          UK GP: $121K
          UK Specialist: $153K

          There’s not quite the same financial reward in abandoning primary practice for specialty care.

          • morebuzzkills

            Salary gap is the main driver. Kid comes out of school, is dissatisfied with the overall quality of his/her 6-figure “investment,” is finally considering the finer points of paying back his/her monstrous debt, might have a spouse, maybe even offspring…looks at salary data for the different specialties, makes the no-brainer decision.

            The issue with trying to fix the situation in the US is that the current specialty salaries are already fixtures for physicians. You can’t reduce them without a bunch of people getting extremely pissed off. PCP salaries must be raised. Few other professions sacrifice as much academically and professionally. This is a gross oversimplification…but the bottom line is that PCP salaries should be brought more in line with specialty pay.

      • buzzkillerjsmith

        What more morebuzzkills said. The main driver of the PCP shortage is the salary gap between specialists and PCPs here in the US. Medical school debt is dwarfed by income differentials. Never forget that most students are very good at arithmetic.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    That stratification in the health care system is not hypothetical any longer. It was probably there to various extents all along, but now it is becoming embedded in policy, and instead of being regarded as unjust, it is increasingly being portrayed as an improvement (e.g. team care, less care, computer care, self care, etc.)
    I am wondering what effect this will have on self-selection for pursuing medicine as a profession. Choosing a lifelong career in tending to the wealthy does not require much idealism and helping rich people doesn’t sound like a calling…

    • buzzkillersmith

      You’re a bit behind the curve on this one, M. The self-selection has been going on a long time. Two recent first year med students I have precepted. 1. I want to be a neuroradiologist when I grow up. 2. Cosmetic ophtho. I want to grow up help people. Actually, mainly their eyelids.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        You’re right…. as usual :-)

      • morebuzzkills

        Margalit and buzz, you should print these statements out and go hand them to every med school admissions committee in the country. Start asking the med students you precept where they’re from, what their experiences were like growing up, what kind of neighborhood they lived in…and you will be surprised by how homogenous the group is. Sure, some of them might have gone to Africa for a summer and posed for pictures with the locals…and written a very eloquent and convincing essay about how the practically eradicated poverty in the village they visited just by breathing its polluted air. A few of them may have even been smacked in the face by the ‘real world’ when they worked as a lab tech while fighting their harrowing battle to get into med school. Covering their rent on a measly $25,000 salary was almost torture (darn near impossible if Mom and Dad hadn’t let them stay on their health insurance and pitched in for gas to drive to and from work). These same students will become neuroradiologists and cosmetic ophthalmologists in the communities where they grew up, live in the same big houses, drive the same fancy cars, etc. The self-selection is indeed alive and hungry…and it is being fed by med school admissions committees all across the country.

        • buzzkillerjsmith

          You must be psychic. Most of the kids are from the Seattle area. Mostly well-scrubbed white youth , many with docs in the family.

          Went to the white coat ceremony last night and several of the kids had gone to Africa to teach nutrition to the starving locals or something. Four weeks and they’re out of there. But the ticket has been punched. Looks good when applying to that anesthesia residency.

          Damn, I’m getting even more cynical. I blame you. Please keep it up.

          • morebuzzkills

            There is no shortage of cynicism on my end. Imagine being in school RIGHT NOW…the saddest part of the story is that many of these kids have started believing their own experiences. It makes for very compelling conversations with classmates. Bottom line (because I love the bottom line): adcoms have to start selecting more based off region and MEANINGFUL experiences (at least in state funded schools). I’m from a very rural area that is close to a less rural (but still rural by normative standards) and there are many kids that I went to school with who could get through medical school and would ultimately come back to the county where they grew up. Unfortunately, the 27 to 30 they would make on the MCAT doesn’t stack up to Suburb John Smith’s 37 MCAT score (achieved after two prep classes). Working at a restaurant, local business, or on a farm is just not as compelling as rescuing an impoverished village with the mere act of respiring. Plus, the skills that you learn when you have to work from age 14 really aren’t all that beneficial in medical school. Proceed with the cynicism at will buzzkillersmith!

          • buzzkillerjsmith

            Damn, you’re worse than I am. BYW, love the name.

          • morebuzzkills

            As a rule, I used to never comment on anything on the internet. However, the combination of medical school small group boredom and the insanity of what I see on the internet made it to where I could resist no longer! My classmates refer to me as a ‘buzzkill’…The sad part is I am probably half your age and not even out of medical school! Oh well!

          • buzzkillerjsmith

            Well, you’re a quick study. I will retract that statement if you go into primary care.

          • morebuzzkills

            Ha, I will report back to you in about year from now. In the meantime, there are many a buzzes to be killed.

  • heartdoc345

    Simple solution. Redo the RVU. Rather than bringing one member of each specialty to the table, bring 1000 docs, with proportional representation of each specialty (so instead of 3 primary care docs out of 18 docs, it would be like 300 out of 1000). And have kind of an auction. And re-do the auction every few years.

    We should have office-based codes of level 6, level 7, for those patients that come with 1000 pages of outside hospital records that take 2-3 hours to review. Maybe then people would be encouraged to think more and test less. And PCPs wouldn’t have to see patients literally every 7 minutes all day long to make a decent wage.

    This would be good not just for PCPs, but for many specialists in non-procedural fields, as well as specialists who could do procedures but prefer more cognitive endeavours. I much prefer spending an hour with a patient to thoroughly explain complex congenital heart disease than spending an hour reading echos, even though the echos presently pay a heck of a lot more money.