Ten Miles Square

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January 30, 2013 10:54 AM Being a Doctor Is Still a Great Gig

By Aaron Carroll

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.

[Cross-posted at The Incidental Economist]

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Aaron Carroll ,MD, is an associate professor of Pediatrics and the associate director of Children’s Health Services Research at Indiana University School of Medicine.
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