pay of physicians soaring since 1966
THE way John Carethers, MD, sees it, the cost of practicing medicine must be measured in emotional terms before a dollar figure can even be discussed. Though that cost is not cheap, he is willing to pay it.On the one hand, "It's draining, very draining," says the young doctor who is in his third year of residency at Massachusetts General Hospital. He regularly treats AIDS patients, most of whom are men about his age. On the other, his "spiritual batteries are re-charged" when he sees strength and dignity in the way a patient deals with an illness. Dr. Carethers is not alone in his point of view. All of the doctors contacted for this article emphasized the primacy of nonmonetary rewards in their practice of medicine. To see a patient well, to diagnose an illness correctly, to heal a young child, or to comfort a family member facing the death of a loved one - there is no way to put a price tag on that experience, doctors unabashedly say. "The joy of practice really lies in the doctor-patient relationship," says Mitchell Rabkin, MD, president of Boston's Beth Israel Hospital and professor of medicine at Harvard Medical College. However, "US physicians earn more relative to average compensation per employee than do physicians of any other OECD country," writes Henry Aaron of the Brookings Insitution in a new book, "Serious and Unstable Condition: Financing America's Health Care." (The OECD, the Paris-based Organization for Economic Cooperation and Development, is made up of 24 industrialized nations.) When it comes to personal finances, doctors hold an understated point of view, says David Rothman, director of the Center for the Study of Society and Medicine at Columbia University's College of Physicians and Surgeons. Traditional medical ethics held the primacy of treatment over cost. Thus doctors could downplay the issue of their earnings. Now, however, the issue is getting increasing public attention. "The precipitous rise in physicians' income in the post-1945 period, particularly in the post-Medicare period [after 1966], helped foster a belief that doctors had become more concerned with their pocketbooks than their patients," Mr. Rothman writes in his book "Strangers at the Bedside" (Basic Books). This, combined with the fact that the "average" doctor is nearly impossible to describe in an era of specialists, means that the medical profession is open to the perception that money matters more than it should, he says in a telephone interview. The way the system is set up, "good income per se is a given," says Siobhan Dolan, just starting her third year as a medical student at Harvard. "Doctors know we will always be able to earn enough to own a home," says Stephen Emonds, MD, a graduate of Harvard Medical School and in his last year of residency at "Mass General." Physician incomes range from less than $50,000 a year in rural and inner-city settings, to well over $1 million in medical specialities like surgery. In 1990 the average doctor's pre-tax earnings were $155,800, according to the American Medical Association (AMA). Roughly half the amount that doctors bill patients goes for overhead and expenses. Physicians earnings increased at an annual rate of about 7 percent in the past decade (3.1 percent adjusted for inflation), according to the AMA. That is well above average for all Americans. There is every indication these gains will continue, even though United States medical schools are graduating new doctors at twice the rate of those leaving the field through retirement or otherwise, and three times the growth rate of the overall population. However, high-earning doctors represent only 10 percent of the profession. The public may believe physicians can easily afford the high premiums for malpractice insurance, and that in some highly publicized cases they have deserved enormous judgments against them. But doctors who earn less must also pay those expensive premiums. There are times when Dr. Emonds wonders about that house he will own. In January his repayment of $98,000 in student loans kicks in. "Before I buy food, pay rent, get a haircut, I have to pay back $880 a month for the next 10 years," he says. He shares an apartment with two roommates to keep expenses down. Like a growing number of younger doctors, he has chosen a career path that will guarantee him a fixed salary and 40 hours of work a week. When Emonds completes his residency next July, rather than start a practice of his own he will be an attending physician in the emergency department at Mass General. It is very unusual for a new doctor today to "go immediately into a practice," says Rothman. He or she will often take a fellowship or a research grant. The norm is 10 years after college before they have a practice. Many women doctors are choosing medical specialties that more closely link them to a clock schedule, says Rothman. A set schedule helps doctors balance their practice of medicine with family life. Young doctors leave medical schools with a mean indebtedness of $46,224, according to the Washington-based American Association of Medical Colleges. They face three years of residency where the average salary in a metropolitan hospital is $30,000 a year for a work-week that ranges from as much as 120 hours at first to perhaps 50 hours in the last year. If there is further schooling after this, they take on more debt. Carethers was 17 at the start of his college studies. He lived at home during both college and medical school in his native Detroit. He attended a state medical school. This let him hold borrowing to a minimum. When he completes his residency, plus the three more years of studies and specialization he plans, he will be 34 years old. He decided to be a doctor at age 17 when he entered college. "I will have spent literally half my life" preparing for a life in medicine before earning "a decent salary," he says. Considering the four years of college, four years of medical school, three years of residency, plus a few more years if a doctor pursues a specialty, "people can feel justified in being paid" a high salary, says Lela Polivogianis, MD, a graduate of Tufts Medical School. "The economic differential between specialities is greater now than it has ever been," says Rothman. "This must have an effect on career choices." Some say the lopsided pay structure is a recipe for resentment, both for doctors and the public at large. The disparity is largely due to itemized payment schedules of third-party insurers or the government. Doctors who specialize in surgery, anesthesiology, ophthalmology, radiology perform what are called "procedures." For each repetition of a procedure, such as removal of a cataract, there is a payment. It is no secret that "a high-powered surgeon will make lots of money," says Rothman. From the point of view of patients, who when polled say overwhelmingly they spend too little time with a doctor, there is a doctor shortage at the level of general care. The general practitioner and pediatrician sit at the low end of the doctor payment schedule. The "gatekeeper" doctor, the primary-care physician, is where the strongest calls for a fixed salary originate. "Salaryism," as it is referred to by older doctors, runs counter to the traditional "fee for service" approach to payment. Younger doctors see a fixed salary as a way to manage time at the office and have a private life. Salaries are most often paid to physicians by health maintenance organizations and hospitals. The underlying philosophy is that no individual decision a doctor makes should result in remuneration or compensation. But "someone who says 'don't call me after 5 p.m.' will understandably make less than someone who is up at 4 a.m.," Dr. Rabkin says. Last week, the federal government announced changes in the fee schedule for doctors under the Medicare program to increase payments to general and family practitioners and reduce the growth payments to specialists. There is another nonmonetary cost many younger doctors pay that the public often overlooks, say doctors. They postpone marriage to an older age than in most professions. And where a doctor's wife used to consider herself "married to medicine," keeping the books, making appointments, putting up with the long hours, she is now more likely to have a life of her own. The male physician will now more often have a spouse who works, who is committed to activities beyond home and the doctor's practice, Rabkin sa ys. This has led to a widespread restructuring of doctors' work habits, he says. Doctors make it clear they are as exasperated as patients with the multiple layers of bureaucracy adding to the cost of medical care. "No one is being served well, and physicians want to be done with red tape and bureaucracy as much as anyone," says Rabkin.