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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.
Yes you’re important
Yes you work hard
Yes you should be well compensated
…
Yes there’s too many barriers to being a Dr … especially just a family practice type
Yes there’s not enough Drs because of the artificial barriers that you ‘ you ‘ put in place
This is your fault / the fault of the institutions that made you
I don’t want several hundred thousand Indian doctors … I want several hundred thousand American doctors with slightly lowered standards
Yeah this is the fault of the doctors. Also, as @2rafa said, they are absolutely overpaid. Very few professionals make anywhere near doctor salaries, and they have incredible status to boot. Doctors are basically the priests of our society.
I say we gut the doctor’s system and open the floodgates to immigrants. High time they earned their salaries. I don’t like doctors for personal reasons anyway, they are far too confident when they shouldn’t be.
I don't think this is true anymore. Anti-doctor viewpoints are super common right now. The left and the right hate us. Corporate media blames us for cost overruns. We aren't independent anymore. Patients murder us and it doesn't make the news. We get threatened all the time at work and the police and the hospital both shrug, even in places where there are specific laws against that.
Look at the tone here. Sure I'm not a perfect communicator but every time I try and refute lies about the AMA I get buried in downvotes, the "doctor bad" and "doctor is the problem" memes are rampant, and that extends to general society.
Not saying it isn't true, just saying that people absolutely feel that way.
For a practical example - you used to be able to get laid or find a partner b/c you were a doctor. Doesn't really work any more.
Fwiw, I appreciate your posts, but don't fret too much about downvotes, that way lies madness. As much as we wish people would vote according to how well an argument is articulated, whether they agree with it or not, I believe most people still use it as an "I agree/disagree" button, and a substantial fraction vote in a reflexively tribal manner.
That being said, while I believe you that being a doctor is difficult and not as rewarding (financially or emotionally) as it might once have been, it's still really hard to convince me that being one of the 4% or so sucks as much as you imply. We could probably do all sorts of reforms that would improve doctor QAL, but some of those would also reduce doctor remuneration, and for some reason doctors seem to prefer the high barriers to entry and what amounts to years of grueling hazing before you're in the money.
I don't think the hostility you describe is some new wave of anti-doctor sentiment. It's a general breakdown in social norms making it more dangerous to be a bus driver or airline attendant or a counter person at McDonalds too. Most hostility about the health care industry is not directed at doctors. It's the hospitals, the front offices, and the insurance companies. And probably nurses take the brunt of patient hostility more than doctors.
I don't think I disagree with any individual thing you said there - downvotes aren't representative and shouldn't be over analyzed, the job and pay are worth it (but less so than the past), people are meaner and angrier in person (to say nothing of online) these days, and so on.
That said - the excess of disagreeableness and decline of respect for institutions and expertise is real (everywhere and sometimes deserved). It's extremely noticeable in our jobs though, because most of life and health takes place outside of the hospital so we can easily see when people don't listen (and come back or die) or make a mess during their stay/visit.
Our oldest can tell us how different it was in Ye Olden Days, or if we work in settings with radically different populations we can see the gap (Vets).
These days we see more and more patients doing things like walking away from treatable cancer to ending up terminal on homeopathic arsenic from someone who is legit licensed in Oregon because that's a thing they do. While I'm not immune to slinging mud at times...people yelling at me on the internet scratches the fundamental same itch writ small.
What bothers me a little more is when people don't realize the decline, especially when it is the respectable types, because of course that hurts more.
Yes I want to be respected (who doesn't?) but it's so intrinsic to the job for us. Yeah its kinda funny when I whinge about it being harder to pick up women as a doctor, but patients shooting their doctors (real but rare), people demanding things that are dangerous to themselves and others like antibiotics for a virus (common as all hell and a problem but individually small potatoes) to the expansion of midlevels because people don't realize how much worse they are (metastasizing everywhere and I'm tired of seeing my patients and friends end up with bad outcomes from it)...these things are real and bringing my end of things closer to collapse.
Like much of everyone's current ills I don't know what the solution is, but I will get on the soapbox and mumble a bit.
And on traditional and all together saltier note, since I was a young intern on call at one point in the distant past: yes nurses get it worse from patients but they totally deserve it.
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Indians who would make up the bulk of these are well known for being modest, competent and not over overconfident.
It was more a line against importing doctors rather than fixing our own issues
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I found many doctors to be dull. They clearly “learned” a lot of material but they don’t seem to have any interesting thoughts or creativity. Maybe the medical field selects for those kinds of people.
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