• Time for a little self-awareness, docs

    I’m still getting hate mail because of that piece I wrote on doctors “struggling to make ends meet“. Guess I can’t help myself. Here we go again.

    I stumbled upon Medscape/WebMD’s annual Physician Compensation Survey. Here are the details:

    Best-Paid Doctors

    The top 10 highest paid doctors are:

    1. Radiologists: $315,000
    2. Orthopedic surgeons: $315,000
    3. Cardiologists: $314,000
    4. Anesthesiologists: $309,000
    5. Urologists: $309,000
    6. Gastroenterologists: $303,000
    7. Oncologists: $295,000
    8. Dermatologists: $283,000
    9. Plastic surgeons: $270,000
    10. Ophthalmologists: $270,000

    Worst-Paid Doctors

    The 10 least paid doctors are:

    1. Pediatricians: $156,000
    2. Family medicine doctors: $158,000
    3. Internal medicine doctors: $165,000
    4. Diabeticians/Endocrinologists: $168,000
    5. Psychiatrists: $170,000
    6. HIV/infectious disease specialists: $170,000
    7. Rheumatologists: $180,000
    8. Neurologists: $184,000
    9. Nephrologists: $209,000
    10. Ob-gyns: $220,000

    Now I can’t vouch for the methods. But let’s accept these results as close to truth for the purposes of this discussion. I bet most of you are looking at that list and thinking, boy, doctors make a lot of money. Even us sad-sack pediatricians are pulling down a pretty nice income. So you think we’d be happy, right? You’d be wrong. About 46% of physicians reported that if they had to do it again, they wouldn’t choose medicine. It gets worse. About 45% say their incomes are no better than that of many nonphysicians. And then, to top it off, only 11% of physicians say they consider themselves rich.

    Please, before the physicians among you start commenting about how I don’t understand you, or that I’m jealous of you, a few caveats. I’m a physician. I took the same college classes as you (I even wrote my thesis in organic chemistry). I went to medical school like you (University of Pennsylvania – cost a fortune). I did residency like you (hated it). I even did a fellowship. So I’ve paid my dues. I know all about educational debt. I know about working ridiculous hours and being treated like crap. And, yes, there are days I feel overworked and underpaid, just like lots of you.

    My point is this – is there any other profession that is as tone deaf as we are when it comes to talking about our livelihood? Is there any other profession that feels so free to complain about making too little, when they objectively make so much compared to so many others? Is there any other profession compensated and respected this well whose members regularly threaten to quit at every possible turn? If any other profession whined publicly about their multiple six-figure incomes like doctors do, they’d be universally reviled.

    I’m not saying physicians don’t deserve it. Nor am I saying there should be salary caps or anything else you want to pull from the “socialism” playbook. I just think we need to take a deep breath and use a little discretion every time we, as a group, feel the need to go all “poor us” in public. I don’t know how much longer the American people are going to tolerate this. Healthcare spending is sinking us. You’d think we’d learn to shut up a bit.

    @aaronecarroll

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    • Physicians are among the highest, if not the highest paid group of individuals in expectation as well. In other words if you somehow found a way to start your life over again and had to decide what to do, your best bet for the highest expected income would be to become a physician.

      I hear physicians complain from time to time about their pay relative to the financial trader or business executive down the street from them despite physicians having to spend considerably more time in school and preparing for their profession.

      What many physicians fail to remember is that the traders and business professionals who live in their neighborhood are the ones who “made it” to the top. They are few and far between.

      This is a classic example of selection bias that leads to the availability heuristic…

    • I’m curious as to the poll results that suggest 45% of physicians see their income as no better than non-physicians.

      Is this simply a matter of perceptional bias due to status exclusion?

      Or, in that physicians can often socially/economically place in a suburban, upper-middle, or upper-class social circle. There they find they work the hardest for their pay among their peers – or that their gross income is lagging? When everyone else in your social circle has an MBA or works in finances or other fields resulting in a greater social/economic status – you see your peers obtaining less education (time or money), with less overhead costs (malpractice insurance, etc) for equal or advanced pay.

      This is a nuanced hypothetical, and may be perceived as me inciting some “class warfare.” But I assure you thats not my intent. I’m generally curious as to what might account for this perception that is not upheld by the empirical evidence? This phenomena may well exist among workers in lower-income positions (perhaps the perception of manual laborers versus technology/information laborers and inherent value of physical toll).

    • Got to think that a lot of the dissatisfaction stems from bureaucracy and the inefficiencies of modern American healthcare, rather than pay alone, If physicians are as fixated on compensation as you imply, why did the number of salaried physicians recently exceed the number of the private docs? Private practice means higher pay but more hassles, and docs are increasingly steering clear. They’re voting with their feet.

    • Well said, from a social worker.

    • Doctors are highly skilled and I fully appreciate that. I have had debates on this subject with friends and acquaintances that are doctors. I eventually ask them the main reason for getting into medicine in the first place. Was it to help people or make really good money?

      • I eventually ask them the main reason for getting into medicine in the first place. Was it to help people or make really good money?

        I know many from school and I think the overwhelming answer is, “everything that I have been told, and what American society has said emphatically since the advance of modern medicine in the 20s/30s, is that both will always go hand in hand.”

        Medicine is a noble profession and has been aggressively sold as a financially rewarding profession simultaneously. For good reason. But there are signs that marriage is cracking more significantly. In perception and wes as in reality.

    • Anesthesiologists are paid twice as much as pediatricians?

      That seems loony.

      It seems like every type of physician that gets in front of problems makes less than those who come in at the last second and put in a heroic (probably hopeless) effort at stopping the end-game of a pathology.

      Siiiiiiiiiiiiiiigh.

    • The other takeaway is that the physicians who keep us well are paid much less than the physicians who take care of us after we become really ill. Possibly as result of this income disparity there are very real concerns about whether the US will have enough primary care physicians to accomodate the millions who will become insured under the Affordable Care Act, or if we will be able to actually implement coordinated care approaches to primary care such as the fabled “medical home.” Considering that so much of our health care spending is focused ontreating preventable and manageable chronic diseases after they become acute, we need more of the physicians who help keep us well.

      • “Possibly as result of this income disparity there are very real concerns about whether the US will have enough primary care physicians to accomodate the millions who will become insured under the Affordable Care Act”

        No need to worry. The supreme court will solve that problem by making sure that we continue to keep tens of millions of people uninsured. The amount of “freedom” lost by entering the health insurance market and the amount of money lost in keeping people from dying are far too big of a price for our Supreme Court Justices to care.

        Just seeing those words “Supreme” and “Justice” make me want to puke. They’re humans, and they will side with their allies.

        Sorry for being such a downer, it took me until the last week to come to terms with this. Just want you to be prepared for the heartbreak. And to start thinking of what we can do when this comes to pass.

    • First, full disclosure: I am a 3rd year medical resident planning to go into primary care internal medicine…

      I believe that physicians are paid plenty. Although we are no longer amongst the most elite earners relatively speaking, particularly when taking into account the average debt burden, we are able to maintain excellent incomes, even in difficult economic times.

      I do see a problem, however, with regards to relative incomes within the profession. That a radiologist should, on average, make twice as much as a pediatrician, is a perversion. In fact, a look at the average lowest paid physicians demonstrates the lesser value placed on prevention, children’s health, HIV, and mental health. The primary mechanism of this discrepancy is a payment system that values invasive procedures much more highly than prevention and disease management, but I believe it also reflects a broader truth in our society demonstrated in wage discrepancies across the spectrum: ie. that caring for the most vulnerable and disenfranchised is almost always undervalued when compared with other activities.

      One result of this is that we have a dearth of primary care physicians which is only projected to grow as older generalists retire and younger physicians continue to choose subspecialization.

      My hope is that new payment models that pay for quality and value, such as those found in the new Accountable Care Organization model, will begin to smooth out these relative income discrepancies within the profession. This would hopefully incentivize more medical students and physicians in training to choose family medicine, pediatrics, and primary care over the currently far more lucrative specialties.

      And lest this be seen as totally self-serving given my own career plans, I would favor a solution that merely decreased the incomes of the highest paid physicians without substantial increases to those at the lower end of the (already high) pay scale.

      • 1. Supply and demand sets the wages and more people want to become pediatricians and work with kids, rather for example than becoming gerontologists and working with the elderly.

        2. Are more women pediatricians and in the profession part time?

    • I agree with most of what has been said above. One intriguing result in that survey with regard to relative pay has not been mentioned: in the last year, the most well-paid specialties have had a substantial drop in income, while the lowest-paid specialties have seen an increase in income. Why?

      I suspect two things are driving it. 1) The highest paid professions may be seeing more of an effect from the bad economy. Fewer people are getting the most expensive care, especially surgeries. 2) Medicare has revised its fee schedule to pay primary care more and other care less. Private plans are increasingly adopting Medicare+ fee schedules, enlarging the phenomenon. And as a result, physicians in surgical and other specialties are complaining.

      So, the equalization has already begun. The question is: how far will it go?

    • I am one of those highly paid specialists (also a Penn grad). I have to agree with Aaron. I run a fairly large group. It saddens me when I hear guys complain about how little we earn. To be fair, I think this comes from a small, but vocal minority. When I chat with my oldest friends, we all agree that we never knew we would make this much, and we are grateful for it.

      I dont have a great explanation for this phenomenon. I think it is partially just people trying to defend what they have. I also think internship/residency screws up some people. having trained in the no limits days (well over 100 hours/week), some people never quite get over that and think they are entitled to anything they can get. Anyway, I tell all my new hires they should consider our current salaries as a bubble event. Pay will decrease.

      Steve

    • By way of comparison, an infantry second lieutenant serving in Afghanistan has a base annual salary of $36,000. A sergeant’s base salary is about $28,000. And 100 hour weeks would seem like a vacation to them. And people are trying to kill them.

      The general commanding in Afghanistan base salary is about $179,000.

    • This reminds of a quote from “Liar’s Poker”, by Michael Lewis, about the attitudes of Wall Street financiers towards their compensation (I’m paraphrasing here): “No one is rich on Wall Street. There are just relative degrees of poverty.”

    • Aaron–

      Nice piece as always. I’m going to give docs the benefit of the doubt when it comes to complaining about their income and say that they have a hard time articulating what the real problem is. I suspect many of the complainers are (like me) running small businesses and are not employed by health systems. Independent docs are not distressed by the clinical practice of medicine—most of us love that, and it is the reason we did this in the first place. The business model is the source of distress and why I complain. I don’t complain about my income—and I totally agree that complaining about making 200K doesn’t engender sympathy. I complain because physicians can’t control fee schedules and reimbursement is largely independent of the quality of the care delivered.

      My ability to negotiate rates with third parties is severely hampered by the fact that my practice is small. A less well trained internist across the street who works for a large health system is certainly being paid more for the same exact CPT code than I am. And there is nothing I can do about it. I’m not really optomistic that reimbursement will be transitioning to a value-based model anytime soon.

      I think if docs were asked the question a little differently they would answer differently—the fact that I have limited control over my income is what aggravates me. Again, this concept is somewhat confined to independent docs.

      I don’t know how much variability there is state to state, but I’m confident that the faculty peds practice at Indiana gets better paid for the same codes than an indepedent pediatrician in the same community.

    • I agree, well done. We docs cannot put on the “white coat” and plead that all we want to do is help patients, etc and then not at least acknowledge that a part of the cost issue in this country is doctors’ income. I said a part. I’m not even sure how big a part, but why should a doc be rich? Until Medicare/Caid it was not the assumption you’d be rich. Comfortable yes. Respected yes. Harried yes. Rich, why? I have yet to meet a doc, face to face who agrees with me.

    • Jon, I’m going to push back on your comments. If I understand your note, you point to the following:

      1) Physicians can’t control fee schedules
      Welcome to the real world. I see this as simply control freak behavior. No one gets to control their fees. They have to negotiate with buyers, consumers, customers and are constrained by what competitors do in every areas of business. Medicine is and should be no different. I have no doubt that many docs have a personality that likes to control things, but this is just crazy to think that you should have this degree of control.

      2) Physicians don’t like that payment is not based on quality.
      I’d like to suggest a revision of that. “Because all physicians think they are better than average, they don’t like that payment is not based on quality. Of course, once you show them data (with admitted flaws) on quality, most physicians begin to fight like crazy to prevent linking payment to quality, because they worry that linking payment to quality will lead to a reduction in their incomes”

      In short, while I probably agree with you that physician complaints about income are more complex than just having low incomes, I also think those complaints are divorced from reality–a reality that means everyone has only limited control on their fees and incomes and many of us provide less quality than we think we do.

    • I agree with you but you should not have to run this gauntlet:

      I took the same college classes as you (I even wrote my thesis in organic chemistry). I went to medical school like you (University of Pennsylvania – cost a fortune). I did residency like you (hated it). I even did a fellowship. So I’ve paid my dues. I know all about educational debt. I know about working ridiculous hours and being treated like crap. And, yes, there are days I feel overworked and underpaid, just like lots of you.

      It is a ridiculous waste of human effort. It is an anachronism.

    • A little OT but teachers and farmers seem to complain more than Doctors.

    • @DShea–

      Your points are fair and my opinions are probably not universally welcomed in the medical community. I’m sure there are docs who would get paid less if they were subject to quality metrics (and maybe I’m one of them). And this has been talked about/attempted for years in Maryland and always failed so I’m not sure it even matters.

      I don’t agree with you on the fee schedule side though. The real world is subject to market drivers—medicine is not. One — the playing field is not even; large health systems can negotiate better fees for their providers so that they are paid more for the exact same product. Medicine is also unique in that the payments come from a third party and not from consumers, customers or buyers.

      In the real world scenario you present I could charge what I want and patients could decide whether they thought I was worth it. If my price was too high they wouldn’t come to me and I would have to change my business model. I don’t have that opportunity. So maybe it is about control, but no more control than any business owner has.

      • I’m going to disagree again, Jon. Size matters in every business, not just medicine. Discounts/rewards for volume occur in every sector of the economy. And, we each choose whether to accept the rewards of being part of a large group (as well as the constraints) or retain our autonomy (e.g., through self-employment, working in a small business, etc.) while knowing we won’t get the benefits of the larger network.

        And many physicians are choosing exactly the option you outline through retainer or no-insurance accepted models, or even simply by choosing to be an out-of-network provider, retaining the right to charge what they wish.

        While there are many features that complicate market mechanisms in health care, these are not unique features and they do make market functions complicated, rather than not functional at all.

    • I read in a German magazine that the average physician in Germany makes 6,400 Euro/month, which translates to just over US$100,000/year. Seems like this could explain a lot of the difference in health care spending between the US and Germany.

      The same article said that inflation-adjusted salaries for physicians had decreased 50% since 1990, which seems incredible.

      Physicians were still the highest paid of all professions.

    • I can sort of understand the cries of poverty, especially in the times we live where the excesses of the finance community are on the pages of the NYT and WSJ every week. Much of that discussion has centered on the “social value” being created. While that term is certainly open to debate, it would be hard not to put doctors toward the top of any list that measures social value. So you have a group that is high end on the IQ scale, obviously hard workers having toiled through years of undergrad, grad, and residency only to end up making fraction of what some guy who knows how to use Excel to melt the universe does. Plus, a lot of them are stuck. You just spent umpteen thousands on an MD, you’re an MD whether you like it or not for a while.

    • Salary, like most other income variables is likely skewed due to “Bill Gates” effects of high-earners. We should be discussing median salaries, since they’re likely closer to the “true” salary of an “average” physician within a specialty. I reviewed the published material (including the slide presentation) and didn’t find any information on the distribution of salaries. I’m suspect.