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Notes -
On physician salaries:
This topic comes up from time to time and is more in the news now for obvious reasons.
Here I will point out that cutting physician salaries does little to address the healthcare cost crisis and also argue that the salaries are deserved.
Obviously yes, I am a physician and don’t want my salary to get cut, but nobody wants that to happen to them, how would you feel if people on the internet were saying you were over-compensated and demanding you take a 50% pay cut?
It’s also worth noting that everybody in the U.S. is compensated well (too well?). That includes within healthcare (see: nurses) but also outside of it. We make good money here; it’s one of the reasons so many of the successful elsewhere want to come to America.
-Okay how much of healthcare spending is doctor’s salaries?
About 8%. If you cut physician salaries by half you get 4% savings. That’s not a little but it is also not a lot.
-Can we do this?
Sure, you could, maybe, but you’ll introduce new problems, people will retire or leave the field, shortages will get even worse, and so on. Depending on how you did it, certain critical fields like surgery would vanish overnight. OB care would be financially impossible to provide (due to incredibly high malpractice burden (can be 150k per year). You can’t spend your entire salary on malpractice insurance and other expenses.
-Okay, but how are physician salaries trending, are you making more than you used to?
Doctors have been getting year after year real wage cuts for 20-30 years. Everyone else’s (in healthcare) salaries have been going up. Percentage of healthcare spending on physician salaries is going down. So, if you really want us to get paid less just wait. Our salary shrinks every year and the portion of the pie we are taking shrinks too.
-Alright, again. So, does cutting physician salaries help?
No not really, we aren’t a large enough slice of the pie and you’d cause a shit ton of new problems. We’ve already seen this a bit. More people are working part time, quitting, dropping out of residency, graduating from medical school and not doing medicine, not providing certain types of services or working in certain locations. That’s with a modest decline in salary and things like an increase in administrative burden and a decline in respect. This would shoot up if you dramatically cut salaries.
-Okay but let us just import a ton of foreign doctors.
Again, 8%. It’s not going to help that much. However, it’s worth keeping mind that a lot of what pisses people off about healthcare gets worse with foreign doctors. Yes, I believe that foreign doctors have worse training and experience than American doctors. People here seem to not like that argument, but we don’t need it. Foreign doctors are almost always coming from third world countries, not Western Europe. People hate when their doctor barely speaks English, spends little time with them, and acts like a cultural alien. All of those things are what cheaper foreign labor brings to the table. Patients in the 90s and 00s heavily pushed better customer service in medicine. It’s made things more expensive but has resulted in better customer service. Walk that back and make things cheaper if you are okay with worse customer service we can do that without breaking everything else.
-Okay DW what’s the most histrionic thing you can say on this topic, just for fun.
If you cut MD salaries by half, I think healthcare costs would actually increase. You’d see a decline in certain types of care which is unexpensive, preventative, and annoying for us to do. Example: nearly every single endocrinologist would stop practicing and go back to doing hospital medicine (they already make less than hospitalists, often to the tune of 150k and have already completed the training for that). All those unmanaged conditions would end up costing more in the long run. You’d also see an increase in “well fuck you, I’m going to be shady now in order to make this worth it.” And you’d see a huge increase in low value – high expense defensive medicine since protecting your salary becomes even more important. A more modest boiling the frog approach is already in use, and involves far too little money to solve the problem.
Switching gears.
-Okay give me some numbers.
It’s hard to tell for a variety of reasons but the number going around right now is an average of 350k (it may actually closer to 300k and we are seeing a complicated post-COVID mirage). That’s a big number but this is a situation where the median and average diverge a lot. Pediatricians often make between 180k-200k. Family medicine makes more than that but not a lot more. Those are a huge percentage of the overall jobs. Yeah, neurosurgeons can make 5-10 times that, but there aren’t a lot of them, and they work close to 24/7, they still make the average weird. A lot of “rich” doctors are a small number of people in a complicated specialty working egregious hours and not really enjoying the money. At one point the neurosurgery divorce rate was over 120%. The median physician has much more reasonable compensation. They also used to make a lot more, the mental framing of this for some is anchored around 90s compensation which just isn’t true anyway. Doctors work a lot. People who run entire departments, manage millions of dollars in research grants, or own patents and other companies are sometimes presented in these numbers.
-That’s still too much.
Okay let us talk tradeoffs. Some things to keep in mind. Doctors don’t typically make money until after they turn 30. Up till that point physicians can often live in more or less in poverty (want to live next to your hospital in the nicest part of a major city on 60k? Good luck). Once you start making money you can start paying off your 500+ thousand dollars in loans. Delightful. Up until that point you have no flexibility. You can’t leave your job or your life is over. You can’t choose where you live. If you get fired your life is over. If your boss is abusive, you say nothing. Probably most importantly, you can’t get back time. Money and time are probably most useful in your 20s. Our peers are meeting partners, going on vacation, clubbing. We are working 24-hour shifts. That’s a huge cost.
-Boring. You chose this.
Fair. But if you want American to keep choosing this you have to be aware, otherwise it ends up like the other jobs that nobody in this country wants to do.
-Okay fine, like is it even that bad of a job though?
Yes. Consider that many doctors are functionally working 2-3 full time jobs worth of work.
-Okay hold up, yeah you work 80 hours in residency but not as an attending and certainly not 120 hours.
Okay, okay lemme explain. Yes, some people are working 80 hours a week (or a lot more) as an adult. However, you are more often doing things like working 60 hours a week, but that is including things like nights, weekends, and Holidays. How many jobs involve regularly working Christmas, or three weeks in a row without a day off, or 24+ hours in a row? Any job with hourly wage and overtime is going to add up to 2 times the base salary really quick under those conditions.
Also, unlike most blue-collar labor (which is laden with mandatory and very real breaks) or white-collar labor (which involves a lot of downtime), most doctors are working nearly 100% of the time while working.
That may sound unfathomable to you, and to some extent varies specialty by specialty but can be very close to literally true. On days when I’m in the hospital for three or meals I’m lucky if I sit down and eat for one of them. Usually if I’m lucky I’m just cramming a protein bar in my face. Trainees always go “what the fuck when do you eat. Or drink. Or pee.” We usually don’t. Surgeons are notorious for regularly giving themselves mild kidney injuries because of dehydration.
Almost nobody I know who isn’t a physician has worked a 24-hour shift. Most people I know have never worked 8 hours in a row for real with no breaks, certainly not for weeks and weeks in a row. Your year-end scramble or Go-Live or tax season is our baseline, and often we are doing it for 24+ hours at age 55.
Once you break this down to hourly wage the numbers get much more reasonable.
-Hold up you work 24 hours in a row with no breaks? Is that real? Isn’t that unsafe?
Yes, at around hour 18 you become disoriented to the point where it’s not safe to drive anymore. Yes, this schedule ends up actually making a lot of sense somehow. Yes we sometimes work more than that, at any given time in a hospital there’s probably someone working a single shift longer than some of the nurses whole work-week.
-Okay but like, outside of the sheer hours it is not that bad right?
Well lack of breaks is part of that. Plenty of other stuff though. Perks are non-existent these days. Most places got rid of the physician lounge and parking lots, which mostly exist to make us faster and more efficient so not the best move in the world. Keep in mind that the chair in my office is maybe older than I am, and most places I work my personal laptop screen is bigger than the screen I’m doing my work on. Most corporate jobs are comfortable. Medicine is not. Little things like that add up and are part of why a lot of us get lured into the general workforce. For some reason I pay for parking.
Also, the job is intrinsically hard. Treat us like kings and pay us millions of dollars a year…and you are still dealing with death and entitled and demanding people all day. You can get sued and lose all your money, your job, or more likely just be miserable for five to ten years while the case gets sorted out in your favor. Most jobs if you make an inattentive mistake, you say oh shit and fix it, or somebody loses some money. Doctor fucks up and somebody dies, and you make thousands of decisions each day where if you lose that focus…
Alcoholism, drug abuse, and depression rates are high. As are suicide rates.
Sidebar: most white-collar work does not involve dealing with the dregs of society. This occasionally makes useful for for instance talking about the practicalities of the criminal underclass but is absolutely stressful.
-Okay but like, not everything is clinical work, right?
Well yes, to some extent that is part of the problem. An increase in charting and administrative work has made healthcare more expensive and restricted supply and quality since I spend less time with and working on patients. Writing bullshit notes does not increase my job satisfaction.
However, there are good other parts – leadership roles, research, teaching. Most doctors are clinical care providers, mentors and educators, and team leaders and managers all at the same time. With the demands of all of those things.
-That’s a lot of shit, anything else you want to unload?
Yeah, there’s other stuff that makes being a doctor be expensive. Board examinations and licensing can cost tens of thousands of dollars. If you get caught smoking weed you could end up losing your job and have to pay hundreds of thousands to get it back for some god forsaken reason. Everyone wants to siphon off of us because they know where the money is. This is also why NPs don’t get sued despite having less training and more bad outcomes. Less money involved.
You constantly get expensive retraining, tests and learning for the rest of your career also. Medicine changes all the time and we are required to stay up to date.
-Okay but like if I’m in the hospital I don’t see you at all what the fuck are you doing?
Operating. Teaching. Calling the lab. Writing notes. Seeing other patients. In committee meetings. I swear we are working you just aren’t seeing it, and a lot of what we do isn’t direct clinical medicine.
-Thank you for coming to my TED talk.
Yeah, this is the eternal threat, right? But ok, what are these people going to do? How many jobs in America are there that pay as much as medicine and aren’t ’top of the corporate pile after a 40 year career’ type jobs?
Very, very few.
A few jobs in big tech. A few jobs in front office high finance. A few jobs in big law. A relative handful in (other) professional services.
None of those professions have medicine-tier job security. All of them (save maybe big tech) have very long hours. All of them are ultra-competitive.
Doctors on the internet always seem to assume they could be investment bankers or deepmind engineers instead, but I don’t think they could. The truth is that medicine is a lot less competitive and more midwit than most of these jobs. Plus, most of these jobs have an extreme up-or-out career progression that medicine just doesn’t have. Of a thousand junior investment bankers at Goldman Sachs who already passed an application process with a 1% acceptance rate, how many become managing directors or seniors in PE? Maybe thirty or forty. Most end up failing out into comfortable PMC professions, often paid less than many medical specialties and again still with far, far less job security.
Plus, there’s status. Nobody in modern American society has higher status than doctors, not billionaires and certainly not bankers, lawyers or engineers. That also has value - socially and for one’s own ego - that can’t be measured solely in pecuniary terms.
Even if medicine paid half as much there would still be doctors. There are still huge numbers of bright eyed, intelligent college students with elite credentials who want to be journalists.
I know you hate that argument so I very specifically didn't make it this time.
Based off your historical unwillingness to update your understanding of anesthesia compensation and work duties I don't think we are going to have a fruitful discussion on the doctor skills/role and work alternatives side of things.
By the way, and I truly am sorry if you’ve gotten that impression, I have a great deal of respect for doctors. I think you do a great job, and I think you should be well-paid for it. And and, I think doctors’ pay is only one part of the issue with the US system’s immense inefficiencies, of which a great deal can be laid at the feet of Congress, insurance companies (not out of ‘evil’ or even the profit motive, but just because of the perverse regulatory and incentive environment they’ve been out in), the way big pharma is funded and to some extent the tragedy of the commons.
My only real ‘thought’ on doctor pay is that we should have more doctors. Let’s train them, let’s import them (from native english-speaking countries with decent standards, like our peers in the anglosphere), let’s do whatever it takes to increase residency spaces. And let’s make residency easier, let’s limit medical liability to bring down the ridiculous cost of malpractice insurance, let’s make medicine an undergraduate course like it is elsewhere so doctors don’t have to waste four years and more money going into debt.
But yes, ultimately, let’s work to bring down some salary costs. Is that so unreasonable?
Do these people want to come? I'm not sure they do.
Usually when this conversation comes up what happens is that I say something like "sure increase supply just don't compromise quality" and then someone says "being a doctor is easy, there aren't really quality differences or problems" I recall this argument from you in the past but if you don't endorse it now no problem, but ultimately most supply increasing options involve compromising quality in some way. Americans are mostly uninterested in decreasing quality, but if we decide that's on the table then we have a lot more tools available to solve some of these problems without touching supply at all.
Also, right now we seem to be in a situation where shortages are pronounced enough that the market can absorb a much higher number of physicians without bringing salaries down. In fact we likely need to increase salaries (specifically: one of the biggest problems right now is that people will refuse to work in red states or rural areas, these jobs already offer higher salaries, sometimes as much as twice as much, but in some cases that's not enough).
We already have some evidence that salaries are too low for some needs, taking salaries down further is liable to make those issues first (and again does little to decrease the overall healthcare costs).
From the UK? I assure you they do.
Why don't they then?
I wasn't able to find a good single source of truth but medical students can do it (which Scott did(ish)) if they are interested. It's harder than it would be a for a U.S. grad but likely much much easier than an Indian medical school grad.
The BMA website implies that some "adult" (saying it this way because I can never remember the British terms) doctors may be able to come over without any specific retraining but does not provide details.
Training is probably somewhat worse in the UK but not enough that I'd have any complaints about anyone coming over (although this would obviously be bad for the UK).
You need to redo your residency if you want to become a US doctor even if you are a consultant with 15 years of experience in the UK. That is enough of a barrier that prevents people from coming over, never mind the extremely onerous visa requirements the US imposes on foreign professionals of every trade and type.
The official stance of the BMA per their website is:
"Doctors who are already on the UK specialist register may be able to apply for partial exemption from the residency programme requirement. To check if you are eligible, you should contact the relevant specialty board in the US."
My guess is that the answer is not yes or no but "it depends."
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