• Being a doctor is still a great gig

    My father, whom I’ve discussed before, is a retired thoracic surgeon who was triple boarded in critical care and ran a trauma unit. When I told him I wanted to be a pediatrician, he was incredibly upset. When I told him I wanted to go into health services research, he acted as if I had told him I wanted to go into ditch digging. I get where he’s coming from. He made a lot more as a surgeon than I will make as an academic pediatrician. But that was not the only concern for me. I wanted to be a pediatrician because I liked the lifestyle more. I wanted to be a researcher because I found the work more rewarding. These have a value that more than make up the money for me.

    Ten years later, my father totally thinks I made the right call. My life is pretty sweet. But lots of other people still don’t think that way. David Dranove may be one of  them. He has a piece today in which he bemoans the ability of physicians to find satisfaction in their lives or make enough money. I’m going to go through most of what he says in detail:

    As kids, our iconic physician was Marcus Welby, the eponymous lead character of television’s top rated drama series. Dr. Welby’s world of an independent private practice, free from interference from administrators and insurers, has ended. Not coincidentally, Marcus Welby was portrayed by Robert Young, who had previously played the lead role of Jim Anderson on Father Knows Best. Our doctors were parent figures, get it?

    Physicians can no longer expect to enjoy similar relationships with their patients.

    I don’t know who he knows in the medical field, but I know lots of primary care docs – like the apocryphal Dr. Welby – who have amazingly tight relationships with their patients. There are pediatricians in my area who are taking care of the kids of their former patients. Yes, its’s true that not all docs practice this way. But that’s always been the case. Moreover, this has been a complaint of docs for decades. Still, many, many doctors still manage to build relationships with their patients.

    In the blink of an eye, the world of medicine has changed. We are witnessing massive vertical integration as providers try to make money from ACOs. At the same time, Medicare and private insurance have gone all-in on pay-for-performance. Only they have forsaken outcomes measurement and instead given us strict process guidelines. As a result of these changes, newly minted physicians can expect to spend the bulk of their careers employed by a hospital or a large multi-specialty group practice. They will not build and maintain a practice – their employer will do that for them. And they will have little discretion over diagnostic testing and treatment plans – they will instead follow strict treatment guidelines.

    As a result of these changes, I see the end of professionalism. Tomorrow’s doctors will not be in loco parentis, instead, they will be more like carpenters or electricians, applying their tradesman-like skills to blueprints laid down by others. No one will place tomorrow’s doctors on a pedestal. Parents will no longer brag to their neighbors, “Let me tell you about my son, the doctor.”

    Let’s unpack this. Accountable care organizations and vertical integration don’t preclude doctors from having relationships with their patients. Being part of a large group doesn’t preclude preclude doctors from having relationships with their patients. I work in a large academic medical center, and many of the patients in the clinic I work in worship the bond they have with their doctors (not me, mind you, but the doctors who are more clinically based). We’re a HUGE group, and that doesn’t stop patients from seeing their doctors.

    Dranove then somehow jumps to guidelines, as if they somehow also interfere with the relationship. That’s just not true either. Guidelines shape how we should treat certain illnesses and conditions. They don’t tell you – at all – how to talk to your patients, bond with them, or treat them as people. Let’s not forget that they also improve outcomes. I help write guidelines, and I promise you that my mother has no trouble bragging about me.

    Medicine will still be a financially rewarding career path. But if money is what matters, there will be far better choices. It will still take 8-10 years to finish medical school plus residency. During that time, a bright young college graduate could have instead completed three years at a top ranked law school and taken up with a big law firm, or worked at a financial firm, gone to a top business school, and taken a job in consulting. Not only would they earn money sooner, as a lawyer or consultant, they would not have to worry about Medicare slashing their fees.

    This has always been the case. If you want to make ridiculous amounts of money, go be a superstar athlete. Or a movie star. Or a partner of some firm on Wall Street. Don’t be a lawyer, because doctors make more. People become doctors most often because they want to be doctors. The reason I went to four years of medical school, three more of residency, and then two more of fellowship was because I wanted to do this job. If I had wanted to make money – and only that – I would have done something else!

    Recent increases in marginal tax rates make medicine even less attractive. College students who choose medicine may give up 8-10 years of good income, but they could reasonably expect to make even more money once they finish their residencies.

    Again, really? Only a fool would give up 8-10 years of good income, unless that was what was required of them to do the job which they wanted to do. People do it because that’s what it takes to be a physician, and that’s what they want to be. And the marginal tax rate? Seriously? It just went up 4.6% on income above $450,000 for a couple. Do you know how few doctors actually make that much? Do you think that an additional 4.6% on money just above that amount is going to suddenly drive people out of medicine? Really?

    If that’s the case, I doubt they were that dedicated to the cause.

    Let’s have some perspective. When my father decided to go into medicine, the top federal tax rate was over 70%. That’s the federal rate alone. That was when Marcus Welby practiced. He seemed to be quite happy being a doctor, and he was able to be quite good to his patients. I’m having a hard time imagining him complaining that a marginal increase to 39.6% would drive him out of medicine.

    Many college students will be wondering why they should give up a solid, steady income today in for a higher income as a doctor in the future, when the government is going to take over half of that higher income.

    These college students are applying to medical school in record numbers.

    When I grew up, I was always told that medicine was a “calling.” Perhaps it was, though the money didn’t hurt. I don’t know how many young people will be “called” to become technicians. But technicians they will be. And with no real financial argument to support the choice, I wonder why anyone would choose to become a doctor.

    Look, it’s a “calling” or it’s not. If it is, then the financial argument is much less relevant. Me, I don’t think it is. Of course, money matters. But it’s not the only reason that people become doctors. If it was, then (as argued above) smart people would do different things. If it was, then no one would become a pediatrician or an internist; they’d all be radiologists and surgeons.

    We can worry about medicine no longer being a “calling.” We can worry about it no longer being lucrative. We can worry about it becoming less enjoyable. But at some point, we have to be honest and acknowledge what it is – a pretty great job. People get to make a difference, they get to make a really good living, and they now get to have some control over their lives. It’s such a great deal that way more people want to do it than are able to. I’m not suggesting that if you really lowered wages things wouldn’t change, but it’s worth keeping some perspective about how “bad” it is to be a doctor.

    Last I checked, this was still a free country. No one is forcing anyone to be a physician. Seems to me that the free market will allow people to decide whether it’s still worth doing, and from what I can see all the evidence still points to it being a pretty good gig.

    @aaronecarroll

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    • My bet is that David Dranove is not a physician and can’t know the bonds that are formed with patients and their families by physicians. As Aooron points out, even those of us in large academic medical centers who are subspecialists bond with families over decades.

    • I love the “NPV of a medical degree might just be worthwhile”, because of 8-10 years of training which apparently is all foregone income. Is that 10 years of foregoing what a high school grad makes? Pretty disappointing coming from someone in his position.

    • I am under the impression that the return-on-investment for medical training is still quite good, on a par or more than that of any other profession for specialists, substantially better than most other knowledge based professions with similar tenure of training — linguistics PhDs, for instance — for primary care. The research is a little old, and, I’m sorry, not top of mind for me to cite, but I don’t think that has changed.

      I suppose it pre-dates the era of bloated executive pay. Maybe that’s it? Not making as much as Croesus? Ah, well, hard to be happy with a Croesus on the block.

      • Here’s an old paper (1994) that calculates ROI for physicians compared to other high-income professions (lawyer, dentist, businessperson): http://www.vaoutcomes.org/papers/Ed_Costs_and_Incomes.pdf

        It concludes that the difference is sizable between specialists and primary care practitioners. Specialists got the best ROI compared to the other professions, while primary care doctors had the lowest ROI. Things may have changed since then, but I imagine the overall trend is still accurate. Consequently, it seems to make sense that we should distinguish between specialists and PCP’s when we discuss issues of physician compensation/ROI.

    • Well done, great post.

    • I don’t mean to over-analyze the man, but he seems to be confusing parental care with a sort of paternalistic control of one’s patients and staff. (“Father Knows Best” indeed!) Having bosses, guidelines and taxes are presented as threats to a doctor’s autonomy, while decreasing compensation threatens the standing and respect doctors have enjoyed. At least that’s how I read his concerns.

      His views are an interesting contrast with Atul Gawande’s 2011 Harvard Med School address, “Cowboys vs. Pit Crews”.

      • Yes, exactly.

        Medicine has long been what sociologists call a dominant profession: they self-regulate to a large extent, they mostly give rather than take orders on the job, they are well-compensated and highly respected, etc.

        That’s fine, physicians deserve it … except for all the hysteria over treatment guidelines voiced by Dranove. Adherence to clinical guidelines is good for most patients, and we know that actual adherence to guidelines is poor. And too many physicians are resistant to adhering to guidelines developed by other physicians, because they don’t like being told what to do.

        And there are at least some physicians who are upset that they’ll mostly be employed by hospitals or large practices, and that they’ll not be owning their own practices. But look at it from this perspective: medicine is a valuable and very rare skill. Therefore, we want to maximize physicians’ output. If they own their own practices, they’ll have to devote some time to running the practice. They’ll have to deal with hiring people, setting up payroll, setting up the utilities, buying the equipment … I’m not saying we should forbid physicians from setting up their own practices, but is it really so bad if they get hired by a larger entity that can handle the administrative stuff and allow them to spend more time with patients?

    • As an economist, let me ask you to be very wary of economists making pronouncements about what’s good for other people!

      Thanks, Aaron, for your perspective as a physician on physicians’ quality of life.

    • It seems to be the same tired old (and very bogus) arguement that economists have often made – that the only thing of value is money.

    • Well written and I dont have a lot to add except, how many people really choose a career based solely upon what they will earn? Did Dranove choose to become a health care economist solely based upon the earnings? Has Austin been holding out on us and he is secretly a millionaire? The ROI on med school remains good. It never has been or will be the primary enticement.

      I keep hoping we will get past the guidelines thing. Guidelines are just a summation of current best practices. They change as we get new info. They are not to be rigidly followed if you have good reason to do something else. Absent those reasons, they should be the default standard. We know, from study after study that absent guidelines, docs do not always follow current best practices.

      Steve

    • I’d be interested in your perspective on the “professional inflation” that is subsuming the physician’s purview: PA’s, nurse practitioners, etc., the trend for which is increasing autonomy and expanding prevalence, particularly in rural and under-served areas. This trend will undoubtedly accelerate with the advent of PPACA.

    • FWIW, in Japan, doctors earn a small fraction of what they earn in the US. (And many work really hard: clinics and hospitals dealing with outpatients here see phenomenal numbers of patients; it’s a way harder gig than being a technical translator.)

      Yet the competition to get into med school here is increadibly fierce and a lot of really smart kids don’t get in.

      Still, being a doctor in Japan results in much higher income levels than engineers, colege profs, and generic white collar business jobs. So it’s still a very good gig relative to the alternatives. (There are almost no lawyers in Japan, so that’s not an option.)

    • 1) “more than half” of WHAT pay?
      I’m sorry, but the way that quote is written it sure seems cagy and hinky… as to gloss over how the marginal rate works, and continue to confuse readers who don’t know what that means. Which is a lot of them. And it seems he’s well aware of this the way that’s written.
      Anyone who reads that should be advised to read this first.
      http://www.mint.com/blog/planning/the-difference-between-marginal-and-effective-tax-rates-1212/

      2) Some of people (and not just doctors) who make arguments like I see in those quotes… they need to get out more!
      They need, for example, to maybe take a look at the work & the life circumstances due to that work, of doctors like Dr. Tom Catena.
      I’m both in awe and even puzzled by Dr. Catena & what I’ve read about his work in Sudan.
      I think his disposition must be rare, and I would never expect most people, or even many, to have the capacity & ability to live his life. But I think it’s important to consider people like that to keep things in perspective.

      Do doctors, doctors who aren’t worried about being able to buy enough groceries for their family not to be undernourished, realize how they sound to the general public when they talk that?

    • For another perspective, those of you with access to the Wall Street Journal may be interested in this piece by a practicing physician, who is worried that doctors may start to unionize.

      http://professional.wsj.com/article/SB10001424127887323375204578270401138739978.html?mod=hp_opinion

      In my opinion, he raises no specific, actionable concerns. He is basically playing to the fears of the WSJ’s main demographic (managers, who hate unions).

    • In Switzerland, where I live now, the patient experience is far superior to the experience I had in the States. I am sure this is due to a large number of factors, but it certainly seems to me that one key reason is that doctors here *don’t* expect to be the richest family on the block. This greatly reduces the pressure to see dozens of patients a day, and doctors’ willingness to take a little extra time with their patients really changes the relationship.