A Medical Hobson’s Choice

In a post titled Ice Bergs and Ice Cubes last week I expressed my opinion that healthcare is at the core of America’s financial crisis, and that the profession of doctor is being corrupted by the medical industrial complex through the auspices of medical societies.  Subsequently there has been discussion among Globe Community bloggers about physicians’ salaries, including speculation that, despite complaints about low Medicare reimbursement rates, medical specialists command such high incomes that they live in mansions.  To that observation I commented:

Marcus Welby, M.D.

Image via Wikipedia

Makes quite a contrast with the historical images of doctors, doesn’t it? Images like Doc Adams on Gunsmoke, Marcus Welby, M.D., or my great grandfather who made rural rounds in Berryville, AR, sometimes for free. Ah, those were the days.

What in fact is the financial picture for medicine these days?  An article in Time Magazine sums it up well.
Under the present system, if you can call it that, physicians are generally graduating the educational pipeline with massive debt and are confronted with a Hobson’s choice on specialization:

The Doctor, by Sir Luke Fildes (1891)

The Doctor via Wikipedia

In 2009, primary-care doctors earned a median salary of $191,401, according to the Medical Group Management Association’s 2010 physician-compensation report. Cardiologists earned a median of $457,310 and dermatologists made $385,088 — doctors who owned their practices earned much more, on average.

What are the motivations of students to become doctors?  One would like to think that high on the list would be humanitarian compassion, and of all the types of practice it is the generalist that most closely relates to the humanity of the patient.  However, if one tried to design a medical education system that would discourage generalists, it is the one we have:

In these tough economic times, most Americans would say that any of those (specialists) incomes seem high. In fact, the primary-care doctor’s gross is often far short of what they need to make ends meet. The average medical-school student graduates with $200,000 in loans, according to the American Academy of Family Physicians (AAFP). This doesn’t include their debt related to four years of undergraduate study. For some students the total debt burden can reach nearly $500,000 — a daunting sum that puts many of them off family medicine. “Money is a bigger influence on these decisions than most students will admit,” Luk says. Plus, specialties offer lifestyle advantages, like more time with family in the long run.

The Time article ends with this:

The recent passage of health care reform legislation offers some improvement to primary-care doctors, but doctors see it as insufficient. “The new legislation adds a 10% bonus to primary-care physicians’ Medicare reimbursement salaries. But this is nowhere near enough. We need to see a 30% to 50% increase in salaries overall to make any real change in the system,” says Dr. Lori Heim, president of the AAFP.

I submit that our medical system is broken.  Medical costs are at the core of the financial crisis and are poised to spiral out of control, and at the core of the medical cost problem is a medical education system that is fundamentally flawed, both financially and morally.  I frankly don’t know how it’s going to get fixed.  The two political parties have an attention span of two years at the moment, and that discourages any fundamental fix.  We need reform of medical education.

Class of 2007, USAF Academy Graduation Hat Hur...

Image by Beverly & Pack via Flickr

Government should, I submit, fund education for doctors just like they do for professional military officers at the service academies.  That would remove the crushing debt and free up physicians to be motivated by service, not money.  What leader will take up this cause?

About Jim Wheeler

U. S. Naval Academy, BS, Engineering, 1959; Naval line officer and submariner, 1959 -1981, Commander, USN; The George Washington U., MSA, Management Eng.; Aerospace Engineer, 1981-1999; Resident Gadfly, 1999 - present. Political affiliation: Democratic.
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8 Responses to A Medical Hobson’s Choice

  1. jwhester says:

    I like your idea about creating something akin to the service academies. I was struck by your contrast between earning only $191,401 for generalists and $457,310 for specialists. That seems like an awful lot of money to me, but it doesn’t seem large to those who routinely borrow an obscene amount of money to go to Med School. Having recently received a masters degree (ministry) I was struck by how the financial industry had managed to get its debt hooks into our society at an even younger age than when I grew up. I would add to you idea one that I borrow from Teach For America. Maybe we could get new doctors to basically volunteer a few years serving a community who cannot afford to pay a six figure salary to a doctor.


    • Jim Wheeler says:

      I think you are exactly on the right track, John. The United States service academies require a minimum commitment of 5 years after graduation in the armed forces in return for the scholarship. Why not require doctors who get a free education to serve in general practice and in areas of the country which most need them? It is a win-win all around, and the doctors get to serve people instead of Mammon.



  2. ansonburlingame says:

    To all,

    An interesting thought to establish a United States Medical Academy or something of the sort. Let’s look however at the math.

    West Point, USNA, AFA and Coast Guard academies graduation around 3,000 men and women each year My guess is the cost is in the range of $200,000 per graduate for the four years. That is $6 Billion per year if my math is correct.

    But it takes at least 8 years to graduate a doctor and at least another year for the internship, so 9 years. So say we graduate 1,000 a year. That is say $500,000 per graduate or $1 Billion per year to “get” 1000 doctors to go where the government so directs them to go for five years.

    Now how many doctors complete their internship each year in the private world? I have no idea but assume is much larger than 1000.

    Then take that 1000 number after 5 years of government service and guess how many will remain in such service. And then consider how many that complete their internship and want to proced immediately into a speciality but cannot do so.

    Interesting idea for sure, but I conclude that “I’m now sure, are you”?



  3. Jim Wheeler says:

    I’m glad you’re sure Anson, but no, I’m not. The physician problem is a big one, as you yourself opined previously when observing mansions. But you raise a very valid point, i.e., that the sheer number of physicians required is quite large. Your comment caused me to delve more deeply into the facts and demographics. It turns out, by the way, that physician residencies are already subsidized to a degree by the federal government.

    The U.S. currently (2005) trains 25,000 doctors a year and may need an additional 10,000 a year. Clearly that’s well beyond the scope of some kind of Medical Academy. But I think there may yet be something sensible to be salvaged from my idea because the problems are still there. The financial motivation problem is still there. We aren’t making enough GP’s and we aren’t getting them to serve sections of the country where they are most needed.

    Rather than, or perhaps in addition to a Medical Academy, why not a program modeled roughly on ROTC? Once a doctor becomes a GP I really don’t think, as you seem to, many would elect to specialize after 5 years. Also, doctors are people and tend to put down roots in a community. I’m guessing that many would stay where they’re needed. Anyhow, these are ideas that I think would help the problem. What are your ideas?

    Thanks for your comments.

    The numbers and some of the thoughts in this comment came from a good USA Today article I found from 2005 at this link:http://www.usatoday.com/news/health/2005-03-02-doctor-shortage_x.htm



  4. ansonburlingame says:

    Well hell, I meant to say NOT (not now!!!!).



  5. PiedType says:

    A belated comment: Many states have programs wherein medically underserved communities pay for or subsidize a medical student’s education, in exchange for which the student agrees to practice for a specified number of years in that community. The hope, of course, is that he will put down roots there and stay permanently.

    Simply graduating more doctors isn’t enough. Distribution is also a problem. Doctors tend to gravitate to larger population centers where they have access to and support from more and better facilities (hospitals, high tech testing and screening, etc.) and specialists for referrals and consultations. Salaries, of course, are also higher in the cities. More doctors in the city does nothing to help people who live hundreds of miles out in rural areas and small communities.


    • Jim Wheeler says:

      I have it on good authority that it is not just states, but individual hospitals, including non-profits, which compete aggressively for doctors by underwriting their educational debt. We are talking a lot of money here and, with the healthcare system in financial crisis I think such transactions should be made publicly transparent by law. Any other opinions on that?


  6. PiedType says:

    Transparency works for me. That is a lot of money and it is an expense of the healthcare system. Full disclosure is only right. Meantime, more power to those communities that employ this win/win arrangement to recruit doctors.


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